HLE | Free Consultation Intake Newsletter Welcome to Her Life Elevated Take a deep breath. This is a safe, gentle space to share what's on your heart. Let's explore how we can walk forward together in wellness, clarity, and confidence.1. Connection DetailsLet's start with how I can best reach you.First NameLast NameEmail AddressMobile PhoneIs it okay to text you about your consultation? Yes, text is great No, please call or email only2. Your Life & FocusUnderstanding your daily rhythm helps me tailor our conversation.Which best describes your work right now?- Select -Full-time employedPart-time employedSelf-employed or business ownerStudentUnemployed/Between jobsFull-time caregiver or homemakerRetiredJob title or type of work (optional)What feels most true for you right now? I feel overwhelmed or I doubt myself I keep repeating relationship patterns or feel confused about a relationship Several things at once and I need whole-person support I am not sure yetWould you like faith woven into your sessions (i.e., Christian counseling perspective, faith-integrated)? Yes Open to it No thank you3. Your StoryPlease share a little about what brings you here today. Take your time.In 2-3 sentences, what is going on that brought you here?How long has this been going on?- Select Duration -Less than 3 months3-6 months6-12 months1-3 yearsMore than 3 yearsWhen does it show up most? (Moments, people, or situations that set it off)What have you tried so far, such as therapy, counseling, coaching, books, or programs, and what helped or did not?What would you like to be different six months from now?4. Current Check-In (Scale 1-10)Rate how things feel for you right now, with 1 being 'struggling' and 10 being 'thriving'.My Stress LevelMy ConfidenceMy Clarity in RelationshipsHow I am functioning day to day5. Logistics & CareA few final details to prepare for our session.Consultations and sessions are virtual online are you comfortable meeting by video? Yes I would prefer a phone callWould you like details about multiple payment options (insurance does not cover wellness services provided)? Yes, please No, thank youAre you currently seeing a therapist or doctor for your mental health? Yes NoIs there anything about your safety right now that I should know? (Optional)Anything else you would like me to know? (Optional)I understand Her Life Elevated/Monique is a Mental Wellness Practitioner and offers non-clinical mental wellness, relationship clarity, and emotional wellness and confidence coaching, not medical advice, prescriptions, or insurance-billable services, and I can seek licensed care at any time.Submit My Connection Details
