Name *

First Name

Last Name

Phone *

Country

(###)

###

####

If yes/maybe, what part(s) of you have been minimized, misrepresented, or outright rejected? Though not an exhaustive list, this is a great place to start exploring your humanity. Please check all that apply. * *

Age

Disability

Diagnosis

Religion or spirituality

Ethnicity or race

Socioeconomic status

Sexual orientation

Indigenous heritage

Nationality

Gender or gender expression

Body type

Emotional expression

Language or accent

Career or job

Change in life, prompting an identity or role shift

Relationships

Other

Have you engaged in any previous therapy, coaching, or self study regarding the above parts? Please check all that apply. *

Therapy

Coaching

Self Study

No dedicated exploration yet