Contact 1 — Rewire for Healing

Thanks so much for reaching out, I can’t wait to meet you and begin your healing journey! If you would like a free consult, please complete as many of these questions as you can to help me prepare for our time together.

with Gratitude,

~Amy Jill 💛

Name

First Name

Last Name

Phone

(###)

###

####

Briefly describe your issue and why you want help with this?

If you woke up and the issue was gone, how would life be different? What would you do differently?

What’s your motivation for change?

What have you done so far to try and figure this out? How long?

What is your goal in working with me?

Do you have the financial resources to invest in yourself?

How committed are you to making the changes necessary to transform your life? 1 (least) out of 10 (most)

How did you hear about me?