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I would like to offer you a free 30 minute extension to your first session in exchange for completing this short survey. 

Age Group:18-2425-3030-3535-4040-4545-5050-6060+

OccupationSelf Employed / Entrepreneur Corporate OfficeSkilled TradeWholistic / SpiritualService IndustryHospitalityTourismGovernment Sector EducationFirst ResponderTelecommunicationsTech / ITRetailSanitation / HousekeepingChild careHealth careFinanceBusiness Admin / CEOReal EstateMental HealthAdult Services / Sex WorkerPersonal AssistantBetween Jobs / Careers Other / None of these

What do you seek right now?

• Connect with partner(s)
• Connect with my children
• Reduce anxiety
• Become more responsive
• Become Less reactive
• Meet perspective partners
• Find more inner peace
• Set boundaries
• Recover from upheaval
• I'm not sure

Describe yourself in 3 words

What is your best personality trait

What's one thing you would like to change or improve in your life?

Name (Or Nickname):

How can I thank you? (Email):

Do I have your permission to:

• Personally Reply
• Check in with you later
• Send you my newsletter

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