Name

First Name

Last Name

Email

Date of Birth Month/Year. Gender Identity

Cell Phone

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What changes do you want to see in your life and what is hindering you the most from making these changes?

When were you happiest? Describe the time and circumstances? How do you feel now looking back?

Think of one challenge/difficulty from your past – what carried you through? What did you learn, if anything about yourself?

I don’t make big changes because?

What is your current resource network like? People? Places? Pets? Teachers? etc

What kind of body mind practices do you have right now?