1:1 Session Application Name: First Last Email: Phone:Age:What are you struggling with when it comes to relationships? Where do you feel stuck? Please be as detailed as possible in regard to the relationship you have with yourself as well as others/ significant other.What steps have you taken previously to try to shift these patterns? (Eg, therapy, courses, reading personal development books, etc). Please be specific with listing any therapeutic modalities that you may have tried in the past.If you have previously tried other approaches, please share what worked and what didn't:What would make the journey of working with me a success from your point of view? Who would you like to be on the other side of working with me?I currently have a wait list. How long are you able to wait? If waiting is not an option, would you like some referrals?Are you currently on any prescription medication? If yes please list what they are, the dose, and for how long.My approach to healing incorporates a variety of modalities, including somatic therapies that are trauma informed. That being said please do disclose if you are currently suffering from any acute mental health disorders or conditions. When embarking on a healing journey it is important to do so with safety and care.How committed are you to embark on this healing journey?Is there anything else you'd like me to know about you in assessing your application?NameThis field is for validation purposes and should be left unchanged.
