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Wholeness 101 Intake Form
Please fill out this form to get on the waitlist and to be notified when more information about
Wholeness 101:
Reclaiming Your Agency Post-Abuse
becomes available.
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Email
*
Your email
Name
*
Your answer
How did you find this program?
*
Your answer
Why are you interested in Wholeness 101?
*
Your answer
Do you consider yourself a victim of any type of abuse?
*
Yes
No
Required
Please give a brief overview of the type of abuse you suffered.
*
Your answer
Do you fully accept that you have been mistreated and did not deserve it?
*
Yes
No
Do you have any diagnoses? Please list below:
*
Your answer
Do you have any medical concerns you'd like me to know about other than diagnoses listed above?
Your answer
Have you worked with a therapist to identify the abuse?
*
Yes
No
How did you come to determine that you were a victim of abuse?
*
Your answer
Are you working any other professionals in the helping field at the moment, ie - therapists, psychiatrists, social workers, wellness practitioners?
*
Your answer
What labels do you use to identify yourself?
Your answer
Have you worked with a coach before?
*
Yes
No
If yes, what kind of coaching have you experienced?
Your answer
Send me a copy of my responses.
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