Confidential Intake Form

To help me get to know you better and understand your unique background and situation, please fill out the following confidential form as a first step.  

It will take approximately 10-15 minutes to complete and you cannot stop midway through and come back later – it needs to be completed in one session.  Please be sure you’ve set aside the time to complete it when you start.  

I suggest you complete this form on a desktop or laptop instead of a mobile device to ensure the information saves correctly.

Please be assured that all information you provide in the form is strictly confidential, and I will not share or disclose any of your personal information to any third party without your written authorization in advance.

After you’ve submitted the form, it will be delivered to me personally and confidentially.  Once I’ve had the opportunity to review it, I will contact you to schedule a relaxed conversation by telephone or Zoom to go over what you’ve outlined. At that point, we’ll each decide if we are a fit for each other. If we’re both “in”, I can then outline the next steps based on what the support and guidance will look like for your particular situation.

My passion is in helping you safely explore your past and what is holding you back so that you can be empowered and feel fully in control of your life. I’m excited for the journey you’re about to embark on — because I’ve been there and know it’s a bit intimidating, but also exciting to think about the possibilities.

So, let’s get started!

(your submission will be confidentially saved and reviewed by me directly.  I will follow up with you within 2 business days)