Adult Survivors of Child Abuse Initial Consultation Form

Please click this area and Indicate by checking the box that you have read and understand the attached Disclaimer and that I am not providing or attempting to provide licensed psychological, medical or counseling services.

Have you experienced childhood abuse?

Check the boxes that best describe the conditions you endured:

Are you now experiencing difficulties in maintaining health and wellness practices in your lifestyle that you believe are a result of childhood abuse?

Check from the following list any current and ongoing issues that may stem from the abuse:

Your Free 60 Minute Initial Consultation Includes: 1- Exploration of your lifestyle history and how self sabotage or self esteem blockages may be interfering with your wellness habits. 2- Primary goals and objectives outline. 3 -Payment and Consultation terms based on your individual needs. 5- Preliminary Program Outline.

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