Clarity Call Please answer the questions below honestly and to the best of your ability. This form must be completed at least 24 hours before our scheduled chat. Name * First Name Last Name Email * Phone (###) ### #### What compelled you to reach out for life/nervous system coaching? * On a scale from 1-10 how ready are you to invest in achieving results in your main area of struggle, on a physical, emotional, mental, and spiritual level? * 1 2 3 4 5 6 7 8 9 10 What is the main area of struggle or concern in your life right now? * What self-improvement or nervous system regulation work, if any (i.e. books, courses, coaching, etc.) have you done previously and what has been your experience with it? * If you are willing to share, please list any psychiatric diagnosis (depression, bipolar, etc.) you may have had in the past and any past or current treatment including past or present medications. If you are more comfortable talking about this in person, please skip this question for now. Do you suffer from gut health issues, autoimmune, or any other conditions I should be aware of? * Your Dream Life Describe the life you would LOVE to live in each of the four key domains of life listed below. Please write these as if you are ALREADY living that life 3 years from now. EXAMPLE: “I'm so happy and grateful now that I enjoy vibrant wellness, strength, flexibility, and abundant energy in my body.” Health & Wellbeing * I am so happy and grateful now that… Love & Relationships * I am so happy and grateful now that… Career & Creative Expression * I am so happy and grateful now that… Time & Money Freedom * I am so happy and grateful now that... Thank you!
