Name

First Name

Last Name

What diagnosed conditions do you have? What suspected conditions do you think you have based on symptoms?

Please indicate if diagnosed or suspected.

Tell me what a typical day looks like for you when your conditions flare up. What symptoms do you have? How does it impact your day? How does it make you feel?

Feel free to be as detailed as you'd like.

How have your conditions impacted your faith, belief and trust in God?

If I could wave a magic wand and get the results you are after, what would those results look like?

What have you tried that hasn't worked?

What results were you hoping to see and why do you think it didn't work?

Have you ever tried anything like this for your pain?

If yes, share your experience. If no, what made you want to try now?

This 6 week program will include us having one 50 minute coaching session each week plus application exercises in between. Is this something you are ready and willing to commit to so your pain can decrease?

Thank you for taking the time to fill this out so I can get to know you better.

I value you.

I fight with you.

And I feel honored that you are considering working with me to help with the pain you are feeling.

Talk soon!

Lots of Love,

Phoebe Grace