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Name

 
Email Address

 
When is your birthday?

 
Where do you currently live?

 
What do you currently do for income? What do you dream of accomplishing in the next five years?

 
Name and describe your 3 most impactful, familial, and/or romantic relationships in your life today.

 
What do you feel is the biggest challenge in your life right now?

 
What kind of relationship do you currently have with your dreams?

 
What do you feel are your greatest strengths? What aspects of your personality do you struggle with?

 
What role, if any, does spirituality and/or religion play in your life?

 
How often do you reflect on how you are emotionally feeling on a given day?

 
If you could change one thing about yourself tomorrow, what would it be?

 
Have you ever been diagnosed with a mental illness?

     
 
If so, which one and what was your course of treatment?

 
Please share anything else you think may be relevant to our work together.

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