Break Free Application Form mia BREAK FREE SYSTEM™Confidential Application FormFirst Name *Last NameEmail Address *1. How long have you been struggling with the issue that prompted you to contact me? *Less than 1 year1-2 years3-4 years5 years or more10 years or more2. How many methods or approaches have you tried in your efforts to break free of the issue? *I haven’t tried any methods or approaches yet.I’ve read articles and books on the topic.I’ve worked with a therapist/counsellor.I’ve tried more than one approach/worked with more than one therapist.I’ve tried multiple things. I get great insight, but no significant change.3. How often do negative emotions (guilt, grief, shame, blame, anger, fear, feelings of loss, dread, anxiety, trauma, heartbreak, powerlessness or other) get in the way of your happiness? *Not oftenRarelySometimesFairly FrequentlyNegative emotions permeate my life.4. Are these negative emotions . . . *Hurting your relationships?Keeping you from living the life you want?Making you angry or upset when something happens to remind you of a past event or events?Sometimes finding you lashing out unfairly at others?Negatively impacting your health, career or financial life?5. What impact do you feel past events have had on your life? *No significant impact as far as I can tell. I manage.I experience occasional unpleasant memories.I experience occasional painful memories.I frequently get triggered by painful memories. They appear out of nowhere.I experience painful memories fairly constantly.6. To what extent do you feel held back in your life (relationships, business, or career) by what happened to you? *It rarely impacts my life.I am seldom aware of its impact on my life.I’m not sure of the full impact on my life but it bothers me on occasion.I feel like my life is still heavily impacted. It bothers me on a regular basis.It affects every area of my life and I’m committed to doing something about it now.7. What are the most important skills you look for in a practitioner? *ProfessionalismYears of experienceA results-focused approachSomeone who is aligned with my valuesSomeone who has walked in my shoes, been there, and has overcome a similar situation to mine.Feel free to add any additional thoughts you may wish to share with me. (Optional)Thank you for your responses. I will be in touch with you within one working day. Mia March 20, 2025
