Get the Healing Blueprint

First Name *

Last Name *

Phone *

Email *

Where are you currently based? (City) *

⁠How long has it been since your last relationship ended? *

Less than 1 month

⁠1-3 months

3-6 months

⁠6+ months

How would you describe where you are in your healing journey? *

I’m still deeply heartbroken and struggling to move on

I’ve made some progress, but I still feel stuck

I’m mostly okay, but I want to rebuild confidence and self-worth

⁠I’ve healed from the breakup but struggle to attract healthy relationships

What do you find yourself struggling with the most right now? *

Have you ever worked with a coach or therapist before? *

Yes (currently)

Yes (in the past)

No (this would be my first time)

Are you ready to commit to your healing journey and take guided steps toward rebuilding confidence? *

Yes, I’m ready now

⁠I want to but I’m nervous

⁠I’m still deciding

⁠If accepted into the program, how soon are you looking to start? *

ASAP

Within the next 2 weeks

⁠Within the month

More than a month away

Healing requires time, energy, and investment in yourself. If the program feels like the right fit, are you able to invest into a range that you would feel comfortable with? *

Yes, I’m ready to heal

No, I’m not willing to invest in my healing journey

If you could fully heal, rebuild your confidence, and attract the right relationship what would that mean for you personally? *