Intake Form Your Starting Point for Authentic Transformation™ Bio-Cellular Reprogramming | Inner Child Healing | Ancestral Patterns This form is not a formality - it is the first step of your transformation.Each response helps us arrive at your session with clarity, presence, and depth.Please answer honestly and from your current experience. SECTION I - ABOUT YOU Full Name Email Phone / Whatsapp City / Country SECTION II - YOUR CURRENT REALITY What best describes your current situation? Entrepreneur/business owner with consistent revenueEntrepreneur/business owner with inconsistent revenueEmployed full-time - exploring growth or transitionEmployed part-time - building something newCurrently not working Patterns or Emotional Imprints I May Be Experiencing Example: I avoid taking risks that could grow my business, I hold back when it’s time to be seen, I don’t always charge what I’m worth, I hold onto money instead of reinvesting in my business, I don’t feel fully worthy of higher income or success, etc. Which area of your life feels most stuck right now? Which area of your life feels most stuck right now? (Select all that apply) Stuck in the same Income or Revenue Ceiling Not feeling aligned with my soul’s purpose Relationships and/or repeating ancestral patterns Physical and/or emotional well-being Something I cannot fully name yet SECTION III - YOUR JOURNEY & READINESS What have you tried? What changed, and what has not? What have you invested so far in trying to resolve this? What have you invested so far in trying to resolve this? (Select all that apply) Therapy or psychology Coaching (business or personal) Somatic or body-based work Inner child work Ancestral or family healing Spiritual practices (meditation, breathwork, etc.) Self-study (books, courses) I have done a lot of work and still feel stuck This is new to me If yes, please share briefly Which services are you most drawn to right now? Which services are you most drawn to right now? (Select all that apply) Inner Child & Ancestral Healing Creating a Soul-Aligned Business Business growth is my priority Personal transformation is my priority I am not sure what I need How would you describe where you are right now? How would you describe where you are right now? I feel ready and committed to invest in the right program and mentor I am interested but not ready to invest yet What would you like to change in the next 6 months? SECTION IV - FINAL DETAILS What resonated most with you that led you to book this session? How did you hear about us? How did you hear about us? (Select all that apply) Workshop or event Referral Instagram LinkedIn Facebook YouTube Google Podcast Advertisement If referred, who can we thank? (Optional) Is there anything else you would like us to know before our session? Sign below. If you need to rectify your signature, click on Clear. If your signatuire looks good to you, click on Save, Finally, click on Submit. Your signature below SaveClear Fecha en la que se firma el acuerdo Thank you for taking the time to complete this form.We look forward to supporting you in this next step of your transformation You are exactly where you are meant to be, at the perfect time This intake is based on over 20 years of experience supporting deep transformation, including childhood, ancestral, and transgenerational patterns. All content is the intellectual property of Silvia Gálvez and Authentic Transformation™. 6 + 8 = Submit
