Questionnaire

Thank you for your interest in a Visit for Your Self with Victor and Steven. Receiving your answers to this form will help us understand the ways in which we might work with you. This will be explored more in a 20-30 minute phone or video call ahead of your Visit.

Each Visit for Your Self is an 8-hour day focused exclusively on an individual or members of an immediate family. If you will be traveling from out of town, you may find this information helpful in planning your visit.

Please fill out the form below and we will contact you. Thank you.

Name *

First

Last

Email *

Phone Number

Phone type

• Cell
• Home
• Work

Modalities of Interest (Check all that apply) *

• Astrology
• Bodywork (Reiki, reflexology, etc.)
• Soundbath (Singing bowls, gong, etc.)
• Tai Chi
• Meditation
• Dreamwork
• Other (Describe below)

Other Modalities of Interest

What led you to seek a Visit for Your Self?

Describe the areas of your life which you would like to explore

or of would

Describe the ways in which you have sought guidance, help or self-improvement in the past

Describe the outcomes of these explorations

What outcomes are you seeking from a Visit for Your Self?

Number of People *

• Individual
• A couple
• Family of 2
• Family of 3
• Family of 4
• Family of more than 4

Additional person

Relationship to you

Additional person

Relationship to you

Additional person

Relationship to you

If you selected more than one person, what would you like to explore together?

Additional comments or questions

Submit Form