Intake Form/ Application/ Breakthrough Call Form

Thank you for reaching out and taking the first step toward greater freedom and transformation. Your responses will help me understand your intentions and determine how to support you best. All information will remain confidential. Please answer openly and from the heart. ❤️

Full Name *

Email *

Phone *

Address

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Country

Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
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Antarctica
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Argentina
Armenia
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Australia
Austria
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Benin
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Bolivia
Bosnia and Herzegovina
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Bouvet Island
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British Indian Ocean Territory
Brunei Darussalam
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Burkina Faso
Burundi
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Cameroon
Canada
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Central African Republic
Chad
Chile
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Cook Islands
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Denmark
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Dominica
Dominican Republic
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Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
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Faroe Islands
Fiji
Finland
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French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
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Ghana
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Greece
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Grenada
Guadeloupe
Guam
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Guinea-Bissau
Guyana
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Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea People's Democratic Republic
Republic of Korea
Kuwait
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Land Islands
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
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North Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
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Martinique
Mauritania
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Mayotte
Mexico
Federated States of Micronesia
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
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Nigeria
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Norway
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Panama
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Peru
Philippines
Pitcairn
Poland
Portugal
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Qatar
Reunion
Romania
Russian Federation
Rwanda
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Saint Kitts and Nevis
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Thailand
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Ukraine
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Virgin Islands, U.S.
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Postal code *

Do you use WhatsApp or Signal to Communicate? *

Yes, I use WhatsApp

Yes, I use Signal

No, I don't use either

How did you hear about me? (If you searched online, what did you search for?

Your Intentions

What inspired you to reach out, and what areas of your life would you like to explore or shift through this work? * (Please share what’s most alive for you—whether it’s healing, growth, emotional healing, intimacy, or personal empowerment). *

What do you imagine could change in your life if these areas came into alignment? * (Describe the impact this transformation could have on your life, relationships, or career). *

What, if anything, do you feel is holding you back from what you desire? * (Be as specific as possible—external circumstances, internal blocks, or both). *

Are you currently in an intimate relationship? * (If yes, what is its status? Is it committed, monogamous, open, dating, etc.? How is this relationship going?) *

Your Background

Have you worked with a coach, healer, or therapist before? * (If yes, briefly share what felt helpful—or unhelpful—in that experience.) *

What are you most proud of accomplishing so far in your life? *

Would you like me to know anything else about your life experiences, desires, current challenges, or past events? *

Financial Readiness

Are you financially ready to invest in this work? *

Yes, I’m ready to invest in myself and my growth.

I have limited financial resources right now and prefer the most affordable options.

I currently don’t have the financial resources to invest in this area of my life.

Consent

By submitting this form, I acknowledge that I am voluntarily seeking personal growth and healing support. I understand this work is not a medical or psychological treatment substitute. *

Agree

Today's Date *

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.