Intake for Coaching with Jayne Anne Ammar
Hello! Thank you for taking a few minutes to fill out my intake form. This form will help me get to know you a little better and will help us be able to quickly gain focus and make progress in our sessions. All answers are completely confidential. If you have any questions, please email me at jayneanneammar@gmail.com. 
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Email *
Full Name *
Mailing Address
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Birthday
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What are you struggling with the most in your day-to-day life? (Please list all emotional and physical issues.) *
How long have you been dealing with these issues? *
What would your life look like if everything was resolved? *
What’s your short-term goal for our work together? *
What’s your long-term goal for our work together? *
What, if any, other kinds of professional or medical support do you currently have? *

On a scale of 1-10 with 10 feeling the most powerful, how much authority do you feel like you have over your health and circumstances to effect positive change?

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I feel like I have no control over my health.
I feel like I am in my power, accept it, and I move forward with confidence.
What didn’t I ask you that you would still like to share?
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