Name
First Name
Last Name
Email
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Phone
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Country
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Date of Birth
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DD
YYYY
Time of Birth
Hour
Minute
Second
AM
PM
Birthplace (Enter City, State, Country name only)
Sexual Orientation (How do you identify sexually?)
Gender Identity (How do you identify your gender?)
Racial Background (Please describe your racial identity.)
Ethnic Background (What is your cultural/ethnic heritage?)
Religious Background (What is your religious heritage or spiritual upbringing?)
Socioeconomic Status (What was your socioeconomic status growing up, and how do you identify now?)
Are there any additional aspects of your identity (e.g., neurodivergent, disability, etc.) that you feel are important for me to understand as I support your healing journey?
Primary reason for seeking healing?
What issues/symptoms are you experiencing and for how long?
Have you previously worked with a therapist or coach? If so, what was that experience like, and what did you learn?
What is your family history?
What is your environmental history (geography, places you’ve lived, cultural, and/or religious background)?
What is your developmental background (school, hobbies, achievements)?
Please describe family and personal mental health history.
What is your romantic relationship history?
What were you taught about relationships and love?
How do you perceive or imagine the 'ideal' relationship should look?
How would you describe your ideal partner in detail—physically, emotionally, and in terms of how they show up and behave in the relationship?
If you were to meet your ideal partner, how do you think you'd feel? Do you ever worry that certain parts of yourself might cause them to lose interest, or do you feel fully deserving of the love and connection you're seeking?
Sexual Satisfaction and Relationship (How would you describe your relationship with sex? Do you feel positive and comfortable with it, or is there room for healing or improvement?)
What is your relationship with sex and sexuality?
What were you taught about sex? How does this impact your view on sex and sexuality today?
Have you experienced sexual trauma?
What is your relationship with fitness?
What is your relationship with food?
What is your relationship with spirituality?
What is your relationship with psychedelics?
Do you have any reckless habits (e.g., excessive drinking, drug use, sex, impulse spending)?
How would you describe your emotional health currently?
What do you do to cope with stress or difficult emotions?
How do you handle conflict in relationships?
What are your biggest fears?
What shame and mistakes are you carrying guilt from in your life?
What are your dreams and aspirations?
What is your relationship with money? (How has money impacted your life and goals, how do you feel about money currently?)
What are your biggest financial fears or concerns?
How do you view wealth and abundance?
What role does money play in your sense of security or freedom?
What does a fulfilling life look like to you?
How do you envision your life in the next 5 years?
What legacy or impact do you want to leave in the world?
Who do you consider your support system? How do they help you thrive?
Are there relationships in your life that feel draining or unhealthy?
What are your personal boundaries, and how do you communicate them to others?
How do you prioritize self-care and self-compassion in your daily life?
What is your career background and history?
What is your relationship with your career and purpose?
Do you feel you've reach your potential and or fear not reaching your potential in life?
What do you feel your "purpose" is in life?
What do you want for yourself and your life? How is that in misalignment with the life you’re currently living?
What do you wish to change currently in your life?
What’s keeping you from living the life you desire?
What will manifesting this new life create for you? How will you know you’ve arrived at your desired destination?
Please use this space to share your life story and any key moments or experiences that have shaped who you are today. What events or periods in your life have influenced where you are now and what brought you to seek healing?
Please use this space to add any more information you feel is relevant.
