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

Street Address *

City *

State *

Country *

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.

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