Application — Dorian Denae

Let’s bloom.

Application

This questionnaire will remain 100 percent confidential, and you only need to complete and answer what feels comfortable to you. The more you are able to tell me, the more I have to work with. That being said you are totally free to leave out anything that doesn’t feel safe at this time to disclose.

With Love,

Dorian

Name

First Name

Last Name

Phone

(###)

###

####

Where do you live?

What are you struggling with? What are you seeking support with?

What are you looking for in a practitioner?

What do you consider to be the biggest core wounds, limiting beliefs, and unconscious defense patterns that you developed in childhood and adolescence?

Describe the top 3 results you would like to get in our container:

Have you ever had a diagnosis of bipolar, Borderline Personality Disorder, PTSD, or any other diagnoses?

What are the most common emotional / physiological states you struggle with (Examples: anger, anxiety, panic, depression, shame, detached, numbness, spaciness, daydreaming)

Check if you struggle with any of the following:

Eating Disorder

Alcohol / Drug Use

Exercising Regularly

Sleeping too much

Sleeping too little

Over Exercising

Addiction

What do you love about yourself?

Have you worked with a coach / mentor / therapist?

check one

Yes

Anything else you would like me to know?