Name *

First Name

Last Name

Phone *

(###)

###

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Check the boxes for each support type you have had experience with in the past, or currently. *

Artist mentor

Spiritual mentor

Peer support

Life coach

Business coach

Career coach

Licensed therapist

Licensed counselor

Group therapy

12-step program

On a scale of 1-7, 1 being hopeless and 7 being extreme joy, where would you rate how you have been feeling over the last week? *

1

2

3

4

5

6

7

Spiritual practices and traditions are a big part of my process. Please share your beliefs with me, so I know how to best prepare for our session. *

I am spiritual and I do not identify with any specific faith group.

I identify and exercise my faith as a Christian.

I am currently deconstructing my childhood Christian faith. I have doubts and questions.

Other