Name *

First Name

Last Name

Are you paralyzed by the thought of the future or past? *

Yes

No

Are you happy with your life today? *

Yes

No

Do you have the inner desire to become something more? *

Yes

No

Do you have relational struggles with people, substances, food and/or body? *

Yes

No

Do you feel stuck? *

Yes

No

Do you trust yourself? *

Yes

No

Do you struggle with showing or receiving love? *

Yes

No