Name

Email Address

What city or town do you currently live in?

How did you hear about me? How did you hear about me? Instagram Facebook Threads Referral Google Search Other

What do you currently struggle with when it comes to insecurity? (Check all that apply) What do you currently struggle with when it comes to insecurity? (Check all that apply) My self-talk tends to be critical and negative I often have a judgmental view of myself I have trouble believing in myself I tend to ask others for their opinion and advice I struggle being alone (and enjoying being alone) I tend to be emotionally needy in relationships I tend to people-please and seek approval I tend to put others' needs over my own I tend to make myself responsible for other people's feelings I have a fear of confrontation I struggle to speak up for what I want I tend to change myself so that I am liked I have a fear of rejection that often keeps me inside my comfort zone I have difficulty facing real or perceived failure I often see others as better than me I often don't feel safe enough to show my real self I'm not sure who my real self is I fear showing my real self

When do you find the insecure and anxious part tends to show up?

How are you currently working on yourself and your insecure patterns already? / what has worked?

What do you want most right now?

Have you worked with a coach or therapist before?

Have you been diagnosed with and/or being treated for a mental health condition or illness? If Yes, please describe and whether you are taking medication for it or not.

Is there anything that I have not asked you that you would like to share with me?

Lastly, this program is a retraining of your old ways of thinking and relating to yourself. In order for you to get the most out of this program, it requires your time, effort and committment to doing the weekly homework, practicing the tools and reading the resources. At this time, are you ready and willing to commit (up to) 2 hours a week (in addition to our hour coaching session) for your growth and transformation? Lastly, this program is a retraining of your old ways of thinking and relating to yourself. In order for you to get the most out of this program, it requires your time, effort and committment to doing the weekly homework, practicing the tools and reading the resources. At this time, are you ready and willing to commit (up to) 2 hours a week (in addition to our hour coaching session) for your growth and transformation? YES! I am fully ready to start this coaching journey! No I'm unsure and want to talk with you more