Zoom Application for Dr. Leah Robbins
Please complete prior to scheduling your free zoom consultation. Thank you!
Full Name*
Email*
Phone
Location/Time Zone*
What are your top three biggest concerns?*
What would you hope to get out of working together? Check all that apply
Relief from Heartache
Relief from Feeling Overwhelmed
You can respond calmly to triggers
Feeling relaxed and safe in my body
Increased enjoyment of life
Decreased Sadness
Decreased Anxiety
Decreased Fear
Decreased Anger
Making better choices and setting better boundaries
Improved performance at school or work
Deeper appreciation for life
Deeper love with your partner
More meaningful connections to others
Positive thoughts about yourself and others
Living your dream life with purpose and meaning
What are these problems already costing you? Check all that apply
Missing out on a thriving career - Living your true purpose everyday
Unable to pay bills due to lack of work
Missing out on Sex/Pleasure/Play/Ecstasy
Missing out on Lasting Love
Missing out on Loving Yourself
Feeling invisible
Feeling isolated and lonely
Missing out on TIME - opportunities you can't get back
Time with children before they are grown
Time with parents before they are gone
Missing out on feeling Joyful and Alive!
Missing out on living life with deeper purpose and meaning
Feeling stuck in life, with no real direction or momentum
Living in survival mode instead of thriving
The consequences of stress on your health
Numbing through drugs/alcohol or sex
At risk of giving up on life
What would you invest now to live your dream life? multiple choice (choose one)*
a. Nothing --- I’m not in a place to invest.
b. up to $400 --- I’d like a map of my healing journey.
c. up to $1200 --- I need some serious immediate relief.
d. up to $4500 --- I’m ready for big changes to improve my life in lasting ways.
e. over $9000 --- It’s time to go as deep as possible to access all the goodness life has to offer.
How committed are you to showing up for this call? (1 to 10)*
How committed are you to showing up for yourself to resolve these problems in your life? (1-10)*
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