Date Of Birth (include time and place of birth):

Occupation:

INTENTIONS

Please list THREE intentions for our work together. Take your time and don't feel pressured to just write something down. We will be revisiting and working with these intentions, energetically infusing them, and utilizing them as a foundation to build upon.

WELLNESS

Average Cycle Length:

E.g., 28 days, 32 days, etc.

Do you menstruate (bleed) regularly/monthly?

("Regularly" means one phase of bleeding every 24-35 days).

If yes, how far along:

Have you ever been pregnant?

Do you have any children?

Height:

Current weight:

(No judgment, ever. This is just a useful way for you to monitor your own progress along your journey).

If yes, please list:

Please explain any condition(s) as needed:

Other conditions not listed above:

If so, how much/often?

Do you have any current spiritual practices (yoga, meditation, Tai Chi, journaling, energy healing, prayer, worship, chanting, rituals, breathing exercises, et c.)? If so, what?

If "other," please specify:

The Bigger Picture

What transformation do you envision for yourself upon entering the Goddess: Activated portal?

On a scale from 1-10, how ready are you to make positive changes in your life?

On a scale from 1-10, how confident are you that you can make positive changes in your life? *

Words of Power

Please write THREE WORDS that describe the WOMAN you want to BE:

Anything else you'd like to share:

Goddess INTRODUCTION