Questionnaire

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Your Time Slot is NOT YET CONFIRMED. We'll hold your spot while you answer a few questions. Your answers will allow us to best help you on the call. Please NOTE, You Must Submit the Form Below to Lock in Your Scheduled Appointment.

“🕊️ Please read each question slowly and prayerfully. Your honest answers ensure you’re matched with the right level of coaching and support.”

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Your First and last Name *

Email *

Phone *

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4. Please share some specifics about your loss. Who passed away? When? What was your relationship to them? *

5. Which best describes your grief journey so far? *

I've avoided dealing with it.

I've tried to process it but keep feeling stuck.

I feel like I've tried everything but still don't have peace.

I've made some progress but I want deep, lasting freedom.

6. Please describe how it’s affecting your quality of life. (Be as detailed as possible. - This is optional.)

7. Which best describes your current state? (This is not optional.) *

I can't eat, sleep or concentrate and it's getting worse.

I feel stuck and overwhelmed almost daily so my social life is gone.

I get better, then worse again when I hear, see or smell certain things.

I've made some progress but still carry deep pain.

I'm ready for relief but I don't want to forget them.

I'm ready to move forward with peace, I just need the right support.

10a. Which best describes your current mindset about healing from grief? *

I believe the responsibility is mine, and I'm ready to take action

I want someone to fix how I feel

I've tried things before, but I didn't fully show up for them

10b. What would keep you from being fully present and accountable in this process? (Think practically: family, work, mental distractions, financial stress, etc.) *

11. Paint a word picture of the greatest outcome and the time frame you’d like to achieve from working with me. *

12a. On a scale of 1-10, how committed are you to working through this grief intentionally over the next few weeks --- even if it feels uncomfortable at times? *

1-2 (Not really ready)

3-5 (Open, but hesitant)

6-8 (Willing, but may need accountability.)

9-10 (Fully committed and coachable. Whatever it takes.)

12b. Are you willing to set aside specific time each week to engage with your portal materials and coaching assignments? *

Yes, I will treat this like a sacred appointment.

I'll try to squeeze it in.

Honestly, probably not -- I'm overwhelmed.

13. Do you have a spouse or partner that you make decisions with? *

A. Yes, and they will be on the call with me.

B. Yes, but they can't be on the call with me that day.

C. No, I make the decisions.

14. If I have a solution that seems to be a good fit, how soon do you want to get started? Choose your start date: *

15a. If it looks like I can help you, do you have access to funding to invest in your healing that leads to connection without forgetting them? *

Yes I have access to funding.

It would be a stretch, but I could make it happen.

I live paycheck to paycheck.

I don't own a credit card.

I need to pay with insurance. (This program is private coaching and not covered by insurance.)

15b. Please give the name of your pastor/chaplain, church, city, and state, with whom you are affiliated.

Church/Organization Affiliation

16a. Finish this Statement: If someone advised me to spend 20-30 minutes per day reading the Bible and talking/listening to God, I would: *

A. ...know it's what any serious person needs to do to grow spiritually

B. ...be a little intimidated, yet with a proven system, I would do it because I'm serious about learning Kingdom principles.

C. ...very much like to learn to hear God speaking to me.

D. ...avoid it at all costs because I want to do things without God

16b. This program is not for everyone. It's for spiritually-minded leaders ready to take radical ownership of their healing, trust the coaching process, and walk forward in legacy and peace. If accepted, will you show up with honor, humility, and readiness to grow? *

Yes

No

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