Intake form In one sentence: What do you want to work on? What is it you want to change in your life right now? Your feedback What behaviors do you display, what feelings to you feel when you are experiencing the issue? Your feedback In 2-3 general sentences, describe what your core family looked like and how you relate(d) to them? Your feedback What do you want or desire (instead of the issue you'll work on)? Your feedback Describe in detail how a day looks different without the issue (what are your thoughts, feelings, activities) Your feedback Name Write your email address here to receive a copy of this feedback form 5 + 11 = Submit Thank you very much for sharing your feedback. Your voice counts!
