“Passionate You” Discovery Session Form
FORM WILL TAKE APPROXIMATELY 10 MINUTES TO COMPLETE
This is a special session to help you get clear on where you are now and what’s standing in your way. I will share powerful tips you can put into immediate use as well as a strategy for long-term transformation!

Must complete the form prior to booking session
All information is Confidential! 
start
 
Date: *

 
First Name: *

 
Last Name: *

 
Phone/Cell #: *

 
What is your Skype ID?
For International inquiries ONLY.

 
Tell me about your OVERALL love or sex challenge, what is your biggest frustration and how is it adversely affecting your life and relationships? (It's important to be SPECIFIC) *

 
What do you have a deep desire to transform so you can be happier in life?   Do you know unfulfilling relationships and low self-confidence adversely affects your income potential *

Select one (1) - Your most pressing concern

 
On a scale of 1 -10, 10 being the most urgent, do you want to resolve this challenge in your life? *











 
[If in a Relationship] On a scale of 1 -10, 10 being the most urgent, does your partner want to resolve this challenge in your relationship?











 
How long have you been dealing with this frustration or need for improvement? *

Select one (1)

 
What have you tried in the past to address this frustration? *

Select the one (1) that you have vested the most time, attention and money with.

 
What were the results of your past efforts *

Select the one (1) that you have vested the most time, attention and money with.

 
What is the specific result or outcome you want to achieve to feel happy and fulfilled? *

 
What would you be interested in learning more about? *

Select ONLY 1

 
Which type of coaching appeals to you? *

SELECT NO MORE THAN TWO (2)

 
Do you have a "commitment to self" mindset?  When you see you need help, you invest the time, energy or money necessary to get the help you need? *

     
 
Are you ready to put yourself first and invest the money to get the support you need? *

     
 
What has stopped you from making the change towards BEing happiness? *


 
What are you ready to invest now to be HAPPY and improve your life? *


 
How did you hear about me? *


Thank you for submitting your request for a "Passionate You" Discovery Session with Stacey Murphy, Certified Intimacy Coach.  
She will contact you within 24 hours to schedule your session.
Click on the button below to schedule your session.
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