Affirmation Personalization Intake Form
Tell us about yourself so we can create affirmations tailored just for you.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Which areas of your life would you like to focus your affirmations on?
*
Self-confidence
Relationships
Career/Work
Health & Wellbeing
Financial Abundance
Personal Growth
Other
What specific challenges or negative thoughts are you currently facing?
*
How would you like your affirmations to sound?
*
Motivational
Calming
Empowering
Gentle
Direct
Other
Preferred Language for Affirmations
Please Select
English
Spanish
French
German
Other
When do you plan to use your affirmations?
Morning
Before Bed
During Stressful Moments
Throughout the Day
Other
How would you rate your current mindset?
*
Negative
1
2
3
4
5
6
7
8
9
Positive
10
1 is Negative, 10 is Positive
Are there any specific words or phrases you want included in your affirmations?
Are there any words or topics you want to avoid in your affirmations?
Which age group do you belong to?
Please Select
Under 18
18-24
25-34
35-44
45-54
55+
Prefer not to say
Would you like to share anything else to help us personalize your affirmations?
Submit
Should be Empty: