Form cover
Page 1 of 1

Full Name

Email:

Mobile Phone (please include country code)

Confidential Information

It's understandable sharing such personal information can make you feel uncomfortable and vulnerable, so please be assured I am the only person who will read this. This information is needed so that I can be sure you can actually 'do' the method as well as get the result. Client safety is my number one priority, and I must have a good overall picture of your current situation.

Your information will be stored securely and confidentially. Without complete openness and honesty, I will not be able to get you the amazing results Creatrix® is getting now for other women, which has been positively life-changing.

Choose the option that is true for you.

1. I am 100% ready for a new life and will take actions to undo the life I've ended up creating for myself. This can mean it can feel like things have to get worse before they get better.

I am willing to do what that takes. I will complete all tasks asked of me prior to, during, between, and/or after sessions, including follow-up questionnaires to measure my progress against my initial pre-Creatrix® responses, at intervals into the future, showing up to all meetings and sessions ON TIME and with no distractions.

1. I am 100% ready for a new life and will take actions to undo the life I've ended up creating for myself. This can mean it can feel like things have to get worse before they get better.I am willing to do what that takes. I will complete all tasks asked of me prior to, during, between, and/or after sessions, including follow-up questionnaires to measure my progress against my initial pre-Creatrix® responses, at intervals into the future, showing up to all meetings and sessions ON TIME and with no distractions.
A
B

2. I have free will and choice in my daily decisions and important decisions about my life. In other words, I have the option to make choices for myself and act on them, even if others may not agree with me.

2. I have free will and choice in my daily decisions and important decisions about my life. In other words, I have the option to make choices for myself and act on them, even if others may not agree with me.
A
B

3. I currently have a supportive person / people in my life.

3. I currently have a supportive person / people in my life.
A
B

4. I am not addicted to mind-altering substances (ie. recreational drugs, alcohol, prescription medications or over-the-counter drugs, etc.). It's ok if you're taking low to medium-dose anti-depressants or anti-anxiety medications.

4. I am not addicted to mind-altering substances (ie. recreational drugs, alcohol, prescription medications or over-the-counter drugs, etc.). It's ok if you're taking low to medium-dose anti-depressants or anti-anxiety medications.
A
B

5. I do not drink more than 3 standard glasses of alcohol a night on 4 or more nights per week.

5. I do not drink more than 3 standard glasses of alcohol a night on 4 or more nights per week.
A
B

6. I have not had a traumatic brain injury (including a stroke or severe concussion).

6. I have not had a traumatic brain injury (including a stroke or severe concussion).
A
B

7. I have not been diagnosed with any mental illness, disease or condition, or panic disorders, beyond mild to moderate PTSD, depression, or anxiety.

7. I have not been diagnosed with any mental illness, disease or condition, or panic disorders, beyond mild to moderate PTSD, depression, or anxiety.
A
B

8. I am not currently on a mental health plan, seeing a mental health professional (OR have been seeing a mental health professional within the past 6 months as a series of sessions) for the same issues I want Creatrix® for.

8. I am not currently on a mental health plan, seeing a mental health professional (OR have been seeing a mental health professional within the past 6 months as a series of sessions) for the same issues I want Creatrix® for.
A
B

9. I am not taking more than one medication (for example an antidepressant stronger than a mild to average dose) or any mind-altering substances (eg. pain medication or sleeping pills) on a regular basis.

9. I am not taking more than one medication (for example an antidepressant stronger than a mild to average dose) or any mind-altering substances (eg. pain medication or sleeping pills) on a regular basis.
A
B

10. I have not had suicidal ideation to the point of planning how I would do it, within the last 9 months.

10. I have not had suicidal ideation to the point of planning how I would do it, within the last 9 months.
A
B

11. I was born a biological female (ie. with a uterus or parts thereof) and understand that this question is important due to how Creatrix® is designed and is in no way discriminatory.

11. I was born a biological female (ie. with a uterus or parts thereof) and understand that this question is important due to how Creatrix® is designed and is in no way discriminatory.
A
B

12. I agree to give FULL disclosure of my personal self, situations, and experiences, and I understand that the facilitator of Creatrix® cannot help me with what she doesn't know about me.

12. I agree to give FULL disclosure of my personal self, situations, and experiences, and I understand that the facilitator of Creatrix® cannot help me with what she doesn't know about me.
A
B

13. We do NOT guarantee any physical health, disease improvements, or illness improvements, and want to be sure you are not having Creatrix® for that reason. Please state you acknowledge this.

13. We do NOT guarantee any physical health, disease improvements, or illness improvements, and want to be sure you are not having Creatrix® for that reason. Please state you acknowledge this.
A
B

14. Have you spoken to a Creatrix® Facilitator/Transformologist® before at all?

14. Have you spoken to a Creatrix® Facilitator/Transformologist® before at all?
A
B

15. Are you a coach or therapist of any kind? If so, please write why you are considering Creatrix® when you have other tools available to you.

16. True transformation requires commitment. Are you ready to invest in yourself to experience the change you desire?

16. True transformation requires commitment. Are you ready to invest in yourself to experience the change you desire?
A
B
C