Private Coaching Application

Please fill out the application from below to request a consultation. Once I receive and review your information I will be in touch. We will work together to create your custom plan.

Name*
Email*
Where do you live?*
Birthdate:
Month
Day
Year
Which type of coaching are you primarily interested in?*
- Relieving pelvic pain, chronic pain, anxiety, or other health issues
- Rediscovering Sex and Pleasure
What are your symptoms?*
How long have you been experiencing these symptoms? When did they start?*
Have you seen a doctor/doctors? Do you have a diagnosis?*
How do your symptoms impact your life?*
Are you on any medications? Please include the medication, what it is for, and how often you take it?*
What have you already tried to heal your body? Include medical treatments and alternative treatments?*
Are you familiar with Mind Body healing? Have you read anything about it or tried any mind body tools or processes already. If so, what have you done and was it effective?*
Tell me a little bit about your overall health, your energy level, and the level of joy, passion and fulfillment in your life.*
Outside of your physical symptoms, what are your biggest challenges? What are you struggling with most in your life? What are your goals? What do you most want to create?*
If you could wave a magic wand and have anything you wanted, where would you like to be in 12 months time?*
What is the number #1 obstacle that keeps you from creating radiant health and the life you want now?*
What personal fears, doubts, and limiting beliefs would you have to release to start living your dreams?*
Describe your biggest struggle or challenge in your sexuality:*
What are you currently satisfied or happy with in your sexuality?*
Tell me your greatest desire for yourself, your sexuality and your sex life. Don't censor yourself.*
On a scale of 1-10 (10 being the highest), how important is it for you to overcome your challenges and find freedom, pleasure, and joy in your body now?*
Please enter a number from 1 to 10.
I offer 3 and 6 month customized private coaching programs with a minimum investment of $2,995 (payment plans are available). Are you able to invest in yourself and your healing at this level at this time?*
- Yes
- No
Why are you interested in private coaching with me? What do you hope to achieve by working together?*
How did you find your way to me?
What questions do you have for me?*
Is there anything else you’d like me to know?