Name *

First Name

Last Name

Phone

(###)

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How would you rate your current stress level on a scale from 1 - 10? *

1 - Living in Paradise on Cloud 9

2

3

4

5

6

7

8

9

10 - Off the charts which are covered in tar and feathers.

What are your top 3 stress-related concerns? *

I can't enjoy anything because I'm always caught up in the crap going on in my head.

I can't sleep.

I'm always in a physical state of fight or flight - My body is constantly reacting to things and doing crazy crap without my permission - I don't even want to be stressed out but my body says otherwise.

I'm super short fused and my relationships are suffering because of it.

I feel detached from everything all the time - like I'm not even in fight or flight anymore.. I'm just.. frozen and distant.

Emotional eating - eating when I'm upset, happy, bored, stressed, or just generally can't stop when I enjoy something.

I keep finding myself attracted to the same type of people that put me in this stressed out state in the first place.

I'm noticing my body is hurting, my skin is breaking out, I don't feel good most of the time, and I'm going to the doctor a lot more but they tell me everything is in my head or just say I'm depressed and send me home with pills.

Something else that isn't listed here