Apply for 1:1 coaching with Teresa

FAST ACTING LOVE SHOT
new client intake form

IMPORTANT:

The following questions address sensitive topics.

All your responses will be received respectfully

and held in the strictest confidence.

First Name

Approximately where in the world are you?

Where are you on your path to the love you want? Describe your situation and current challenges.

How are these challenges affecting your well being?

What have you already tried? What were the results?

Who or what else is being impacted by challenges in your relationship and how?

How would your life be different if you had EVERYTHING you want in love / relationships?

What (if any) additional cultural, social, situational, or family aspects do I need to understand?

Are you willing to learn more about yourself and experiment with new ways of relating?

YES, I'm readyyyyyyy!!!!

Eeek, I'm scared but... I think so!

I'm skeptical but interested in the possibility.

Nah, I just want others around me to change.

Thanks for submitting!