Pre Enrollment Application
Must complete questionnaire for program consideration. Please allow 48 - 72 hours for response.
Email address *
First/Last Name *
Your answer
Telephone Number *
Your answer
Are you in crisis? If "yes", answer next 2 questions. If not SKIP next 2 questions. *
Your answer
Are you in physical danger? If so, call 911.
What is the nature of your crisis? *
What is the situation that led you to contact me? *
Your answer
How long have you been dealing with it? *
What is your anxiety level around the issue? *
Do you have a hope for how this turns out or an "ideal resolution" you're hoping for...what is it? *
Your answer
Have you tried other things/therapy/coaching to resolve this issue? If so, what? What were the results? *
Your answer
Are you willing to have your beliefs challenged to help bring about the mindset transformations needed for a healthy, positive outcome? *
What else do you want me to know about your situation before we speak? *
Your answer
I understand that the call is being recorded and that it is confidential. *
The following is true, I... *
Where did you hear about me?
Your answer
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