Section One: Session Focus

Your Stargate 21-Day Transformation practitioner

Which outcome feels most important for you to create in this session?

A calmer, more grounded mind with less anxiety and overthinking

Healthier, more secure relationship patterns and connections

Clear life direction and a stronger sense of purpose and motivation

Confidence, self-trust, and a stronger sense of self-worth

Freedom from past experiences that still affect how I feel or react

Other (please describe)

In your own words, what feels most important for you to change right now?

When did you first notice this becoming a problem?

Does this feel constant, or does it come and go?

It's constantly there

It comes and goes

What situations, people, or thoughts tend to trigger it most?

How does this affect your day-to-day life?

On a scale of 1–10, how intense does this feel in your life right now?

Section Two: Background & Childhood

How would you describe your relationship with your parents growing up?

Do you have any siblings? If so, please name them and your relationship with them growing up.

How would you describe the overall emotional tone of your childhood?

Is there anything else you would like your practitioner to know about your childhood experience?

Section Three: What You Want Most

If this session was an absolute success, what is the most important outcome you’d love to see?

What would your new day-to-day life look like?

How would you feel emotionally?

How would you think differently about yourself or your life?

Agreements & Safety

I confirm that I have not been medically diagnosed with Bipolar Disorder, Schizophrenia, Psychotic Disorders, or Personality Disorders. I understand these conditions are outside of Stargate’s scope of practice.

By checking this box, I confirm that I have read and agree to the Terms & Conditions, Privacy Policy, and Disclaimer.

First name

Last name

Client Acknowledgement & Signature

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NEXT STEPS

A session built for you

Section One: Session Focus

Section Two: Background & Childhood

Section Three: What You Want Most

Agreements & Safety