EAA Application

This application is completely confidential and serves to help me understand more about any history of emotional or physical abuse/trauma you may have experienced, so that I know how to best support you during our time together.

Click the button below to start.

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BACKGROUND INFORMATION

Please commit 5-10 minutes to complete this
application without interruption.

If you walk away, it will not save your responses and you will have to start over from the beginning.

Question 2 of 40

First and Last Name

Paragraph answer

Question 3 of 40

Mailing Address (including street address, city, state, country and zipcode)

Paragraph answer

Question 4 of 40

Best Phone Number

Paragraph answer

Question 5 of 40

Instagram Handle and/or Facebook Name (I wanna be your friend!)

*Please note which of the two platforms you prefer!

Paragraph answer

Question 6 of 40

Date of Birth* (include m/d/y)

Paragraph answer

Question 7 of 40

Email address*

Paragraph answer

Question 8 of 40

How did you hear about EAA?*

Paragraph answer

Question 9 of 40

Current Relationship Status:

A

Single

B

Single w kid(s)

C

Married

D

Married w kid(s)

E

Divorced

F

Dating

G

Other

Question 10 of 40

What's your profession?

Paragraph answer

Question 11 of 40

Do you smoke? (either currently or previously)

Paragraph answer

Question 12 of 40

Do you drink (alcohol)?
(if yes, write what kind and how often)

Paragraph answer

Question 13 of 40

Do you suffer from irregular bowels or bloating? (if yes, describe how often and how long its been going on)

Paragraph answer

Question 14 of 40

Do you suffer from headaches/migraines, skin issues (eczema, rashes, acne, etc), mood swings, irregular cycles, poor sleep, reliance on caffeine (coffee or energy drinks) or carb cravings/binging?

Paragraph answer

Question 15 of 40

Do you suffer from energy crashes/low energy? (if yes, describe how often on a daily and weekly basis)

Paragraph answer

MEDICAL BACKGROUND

Question 17 of 40

Medical Information:

(Select all that apply)

A

High blood pressure

B

Low blood pressure

C

Cardiovascular disease

D

Stroke

E

Heart Condition

F

Pacemaker/Heart attack/Angina

G

High/Low Cholesterol

H

Diabetes/Pre-diabetes

I

Blood Disorders

J

HIV

K

Liver Disorders

L

Thyroid Problems

M

Respiratory Disorders

N

PCOS/Endometriosis/Fibroids

O

Hernia

P

Hearing Difficulties

Q

Vision Impairments

R

Glaucoma

S

Retinal detachment

T

Epilepsy or other seizure disorders

U

Family Hx of aneurysms

V

Migraines

W

Frequent dizziness or vertigo

X

Kidney Disorders

Y

Urinary Incontinence

Z

Cancer

AA

Metal Implants

AB

Birth Control/IUD

AC

Osteoporosis

AD

Anxiety/Depression

AE

Hx of panic attacks, psychosis or disturbances

AF

Severe mental illness

AG

None of the above

Question 18 of 40

Explain all checked:
(write N/A if none applies)

Paragraph answer

Question 19 of 40

Medications, currently taking:
(write N/A if none applies)

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Question 20 of 40

Major Surgeries? (If yes, please describe)

Paragraph answer

Question 21 of 40

Any Allergies? (If yes, please describe)

Paragraph answer

Question 22 of 40

Do you have any NECK, BACK or JOINT pain? (If yes, please describe)

Paragraph answer

Question 23 of 40

Do you have a history of severe emotional trauma? (sexual, domestic, verbal abuse; abandonment, etc)

Paragraph answer

Question 24 of 40

Have you been hospitalized in the past 12 months? If yes, please explain

Paragraph answer

Question 25 of 40

Have you ever done breathwork? If yes, what's your experience?

Paragraph answer

SELF-ASSESSMENT

Question 27 of 40

What are the top 5 emotions you experience on a daily or weekly basis?

Paragraph answer

Question 28 of 40

When conflict or fear arises, how would you describe your initial reaction?

(Select all that apply)

A

I become small and try to hide; I try to avoid being seen at all costs

B

I burst out in anger or rage and often do/say things I later regret

C

I assimilate into my environment and do whatever it takes to maintain peace

D

I get quiet and keep to myself, wanting others to "leave me alone"

Question 29 of 40

From a 1-10, how happy are you with your LIFE as it is right now?

A

1-3

B

4-6

C

6-8

D

8-10

Question 30 of 40

From a 1-10, how happy are you with your BODY as it is right now?

A

1-3

B

4-6

C

6-8

D

8-10

Question 31 of 40

In a few words, how do you describe your eating?

Paragraph answer

Question 32 of 40

In a few words, how do you describe your body?

Paragraph answer

Question 33 of 40

In a few words, how would you describe yourself as a person?

Paragraph answer

Question 34 of 40

In a few words, how would you describe your family dynamic growing up?

Paragraph answer

Question 35 of 40

To your knowledge, what are (3) limiting beliefs/stories/mental blocks you have that play on repeat in your mind?

Examples:
"I don't have time"
"I always fall off track"
"I'm not enough"
"I'm always behind"

(if you are unsure, type N/A)

Paragraph answer

Question 36 of 40

What would be the top 3 outcomes you would be looking to accomplish together during these 6 months?

Paragraph answer

Question 37 of 40

List 3-5 of your personal CORE VALUES:
(i.e. wealth, happiness, loyalty, health, integrity etc)

Paragraph answer

Question 38 of 40

This program is a 4-figure investment (with both PIF and payment plan options) and requires your commitment for 4 months.

We will be working together to help you heal on a deep, empowering level.

Knowing this, how committed are you to your own transformation?

A

I am 110% ready to get started and make a change in my life!

B

I am about 80-90% committed, but I'm afraid to take the leap..

C

I want to but I'm feeling so much fear right now

Question 39 of 40

Any additional info that I should know?

Paragraph answer

Question 40 of 40

Let's do a quick check-in:

How are you feeling right now after completing this application? Are there any fears coming to the surface? Is there anything coming up for you mentally or physically?

LMK - I'm here to help you work through it ❤️

Paragraph answer

Confirm and Submit

Name

Email

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EAA Application

Click the button below to start.

BACKGROUND INFORMATION

First and Last Name

Mailing Address (including street address, city, state, country and zipcode)

Best Phone Number

Instagram Handle and/or Facebook Name (I wanna be your friend!)*Please note which of the two platforms you prefer!

Date of Birth* (include m/d/y)

Email address*

How did you hear about EAA?*

Current Relationship Status:

What's your profession?

Do you smoke? (either currently or previously)

Do you drink (alcohol)? (if yes, write what kind and how often)

Do you suffer from irregular bowels or bloating? (if yes, describe how often and how long its been going on)

Do you suffer from headaches/migraines, skin issues (eczema, rashes, acne, etc), mood swings, irregular cycles, poor sleep, reliance on caffeine (coffee or energy drinks) or carb cravings/binging?

Do you suffer from energy crashes/low energy? (if yes, describe how often on a daily and weekly basis)

MEDICAL BACKGROUND

Medical Information:

Explain all checked:(write N/A if none applies)

Medications, currently taking:(write N/A if none applies)

Major Surgeries? (If yes, please describe)

Any Allergies? (If yes, please describe)

Do you have any NECK, BACK or JOINT pain? (If yes, please describe)

Do you have a history of severe emotional trauma? (sexual, domestic, verbal abuse; abandonment, etc)

Have you been hospitalized in the past 12 months? If yes, please explain

Have you ever done breathwork? If yes, what's your experience?

SELF-ASSESSMENT

What are the top 5 emotions you experience on a daily or weekly basis?

When conflict or fear arises, how would you describe your initial reaction?

From a 1-10, how happy are you with your LIFE as it is right now?

From a 1-10, how happy are you with your BODY as it is right now?

In a few words, how do you describe your eating?

In a few words, how do you describe your body?

In a few words, how would you describe yourself as a person?

In a few words, how would you describe your family dynamic growing up?

To your knowledge, what are (3) limiting beliefs/stories/mental blocks you have that play on repeat in your mind? Examples: "I don't have time""I always fall off track""I'm not enough""I'm always behind" (if you are unsure, type N/A)

What would be the top 3 outcomes you would be looking to accomplish together during these 6 months?

List 3-5 of your personal CORE VALUES:(i.e. wealth, happiness, loyalty, health, integrity etc)

This program is a 4-figure investment (with both PIF and payment plan options) and requires your commitment for 4 months. We will be working together to help you heal on a deep, empowering level. Knowing this, how committed are you to your own transformation?

Any additional info that I should know?

Let's do a quick check-in: How are you feeling right now after completing this application? Are there any fears coming to the surface? Is there anything coming up for you mentally or physically? LMK - I'm here to help you work through it ❤️

Confirm and Submit

Instagram Handle and/or Facebook Name (I wanna be your friend!)

*Please note which of the two platforms you prefer!

Do you drink (alcohol)?
(if yes, write what kind and how often)

Explain all checked:
(write N/A if none applies)

Medications, currently taking:
(write N/A if none applies)

To your knowledge, what are (3) limiting beliefs/stories/mental blocks you have that play on repeat in your mind?

Examples:
"I don't have time"
"I always fall off track"
"I'm not enough"
"I'm always behind"

(if you are unsure, type N/A)

List 3-5 of your personal CORE VALUES:
(i.e. wealth, happiness, loyalty, health, integrity etc)

This program is a 4-figure investment (with both PIF and payment plan options) and requires your commitment for 4 months.

We will be working together to help you heal on a deep, empowering level.

Knowing this, how committed are you to your own transformation?

Let's do a quick check-in:

How are you feeling right now after completing this application? Are there any fears coming to the surface? Is there anything coming up for you mentally or physically?

LMK - I'm here to help you work through it ❤️