Application Form

Application Form
Name*

First NameLast Name
Instagram handel *
Phone Number
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Email*
example@example.com
Please select your Time Zone*
Where did you hear about me?*

InstagramFacebookWord of mouthNatural Therapies Pages
Why are you are reaching out?*
What are you hoping to get out of our call?*
What results would you like to achieve?
What would you like to accomplish in 12 weeks?*
What is your #1 goal that once solved would make life 10x better?*
Which of the following best fits your goals*

Anxiety & Emotional RegulationPost Relationship HealingChildhood Trauma HealingOther
What would you like to see happen after 12 weeks with Adele?*

Overcome Panic AttacksGain confidence and self esteemAchieve Emotional RegulationHeal Post RelationshipOther
Roadblocks
What limitations you currently facing?*
What are the top 3 things keeping you from reaching your goal?*
A FULL BREAKTHROUGH focuses on Emotional Regulation, Resilience, Accountability and Discipline as core principles, which do you struggle with most?

Emotional RegulationResilienceAccountabilityDiscipline
What would you like my help with most? What do you want me to help you with?
Qualifier
On a scale of 1 to 10 how important is solving this problem to you right now?
Are you willing to make a 4 figure investment to solve this problem?

YesNoNeed Payment Plan
Are you willing to do whatever it takes to this problem?

YesNo
Should be Empty:

What results would you like to achieve?