PSYCH-K® Breaking Through Your Blocks Intake Form

Stressful situations from the past, present or excessive fear for the future causes us to stay in fight or flight wreaking havoc on our sympathetic nervous system. Staying in this mode can have negative impacts on your emotional, physical and mental health. We are so proud of you for creating generational change by allowing us to transform and rewire/reprogram your perception in minutes.

First Name *

Last Name *

Phone *

What's your biggest struggle or challenge right now? (can be anything from needing to forgive someone that hurt you, imposter syndrome, parenting, fear of driving on the interstate/in snow, etc., smoking, addicted to sugar, money/scarcity, confidence, anxiety, etc.)

Most of us suffer from a truckload of unhealed trauma...Is there an event, trauma or situation from the past that even today when you think about it causes anxiety? If so and you're comfortable sharing, please do so as we can help flip the script and gain freedom around. The more detail I know the more freedom I can help you achieve.

What would you rather have instead? Paint as vivid a picture as possible.

What's keeping you from being the most authentic, vital YOU?

What do you love and celebrate about yourself?

Do you or are you able to express yourself creatively? If not, do you feel that there's something within you dying to come out but you don't feel confident enough to persue it?

Do you feel financially healthy in your life or do you live with scarcity?

If your fairy godmother could change 1 thing for you to help you show up differently what would that be?

What will you see in your life that will let you know you've achieved your goal?

What will you hear people saying about you and what will you be saying to yourself when you gain this freedom?

How will you feel when you gain this freedom?

Do you experience pain anywhere in your body? If yes, where, severity, frequency, pain level 1-10

What are your spiritual/religious affliliations?

The cost for this session is $444 US. Do you commit to payment before the session? *

You bet!

Enter your coupon code here if you were given one.

I'll pay using:

Venmo @Hilary-Porta

PayPal "friend to friend" [email protected]

Zelle Hilary 704-491-9161

Venmo @Moletelfer

Paypal "friend to friend" @edwardtelfer1

Zelle Mole 954-990-9244

I understand and agree that I am responsible for my own life and it's unfolding. Since I'm a Rock Star and OWNING my future, I'm seeking assistance resculpting my beliefs but the actual manifestation is up to me. I'm committed to my session(s) and I also understand that any cancellations less than 24 hours prior to my session forfeits the session unless an emergency. *

Yep, Got It!