Full Name *

Gender *

Mobile or WhatsApp Number *

Email *

Location *

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How Did You Hear About Us? *

Have you watched or read Ariel’s content? If so, what resonates?

Have you taken any courses, attended classes, or retreats she’s led? When, Where?

What do you do for work? Please describe.

Please describe your family situation (number of children, married, widowed, divorced, single).

What are your primary sources of stress? Please list all the ones you can think of.

What’s the biggest challenge you’re facing right now?

On a scale of 1 to 10, 1 being the least, 10 being the most, how do you feel about:

How committed you are to changing?
How urgent are the changes?

Have you sought and/or followed any psychotherapeutic or psychological help, taken any courses, attended classes or retreats, participated in AA, NA of any kind in the past. Please list what, however many you remember, when and where?

If yes, which are you still participating in?

How do you feel Ariel can support you?

Working with Ariel requires a significant Energy Exchange - beyond a deep commitment to change, a willingness to fully invest in the process is essential.

YES

NO

If there is anything you’d like to share with me that hasn’t been addressed above, please share.