"Claim Your Shine" Assessment Call Intake Form

First Name

Last Name

Email *

What Country Do You Reside In? *

Phone Number *

Do You Speak English? *

Yes, I speak English

No, I do not speak English

What is Your biggest energetic block right now? Select all the apply *

I feel "stuck" and "burned" out after Client Sessions

I know I have more to offer, waiting to awaken within me

I seem to be hitting an invisible ceiling in Client healing results

I desire more confidence in my healing abilities

I feel I am operating in lower the dimensional frequencies - from D1 to D4, and seek to operate at D12 or higher

I am struggling to grow my practice and with self confidence

What healing, energy work, or coaching modalities do you currently use in your practice? *

What is your primary goal for you practice over the next 6-12 months? *

What have you tried in the past to make a break through? *

Are You currently experiencing psychic attacks or have you in the past? *

What do you believe is actually stopping you from making progress? *

Share anything you would like me to know about You.

This Energetic Assessment is designed for dedicated practitioners who are ready to correct template distortions and expand their practice. That being said, are you ready to invest time and resources into your growth, assuming we both feel it is a good fit? *

Yes, I am ready to invest in myself, and can find the resources, if I believe I have found the right person that can help me.

No, I have no flexibility to invest, even if I found the right person to help me.

I'm just looking for free information right now

I understand that if I Book this Assessment Call and do not show up, ghost, or blow off the meeting, that the opportunity to continue our working relationship will be terminated *

Yes, I am 100% sure I will be there.

No, by selecting this option my appointment will be canceled

A current Photo of Yourself MUST be uploaded to proceed *

Click to upload

PNG, JPEG, JPG, PDF, DOCX or DOC

I am not a Robot Verification:

By checking this box, I consent to receive non-marketing text messages from YLBA about "Claim Your Shine" or D12 Kathara Healing. Message frequency varies, message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

By checking this box, I consent to receive marketing and promotional messages including special offers, discounts, new product updates among others, from YLBA at the phone number provided. Frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.