MentoringQUESTIONNAIRE Name * First Name Last Name Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Date of Birth * MM DD YYYY Exact Location of Birth * Exact Time of Birth * Do you have a partner? * Yes No Do you have children? * Yes No Choose an Element. * Earth Air Fire Water Ether Choose a Color. * Purple Blue Green Yellow Orange Red Choose an Animal. Dove Dolphin Turtle Snake Hawk Lion Please list the parts of your physical body that cause you pain or discomfort. * When I say the word "seld-aware" what does that mean to you? * Do you feel resistance within your body around intimacy within your relationships? * Describe in a few sentences the reality you see happening around you within the world. * Let's type it out : At the end of our time together, what do you desire to both manifest and embody within your experience? * When you close your eyes and meditate, what do you see within your minds eye that surrounds you? What do you envision that represents safety to you? * Please share below any other information you feel I should know or would like to share. * By typing your name below you understand that I (Britt Johnson) cannot guarantee results, your privacy is securely protected and your well-being both emotionally and physically are of the highest importance within this space. * By checking the box below you agree to the Privacy and Refund policies. And that you are now aware that the information regarding these policies is available and listed on britt-johnson.com * I Understand. Thank you!