THRIVING BREAKTHROUGH Consult REQUEST/PREP

Request and Prep for Your
Complimentary 45-Minute
THRIVING BREAKTHROUGH Consult

(by Zoom Video; Phone Consult available by special request)

I'm delighted that you're looking at taking the next step in reclaiming your grounded clarity, confidence, and power, and honored to support you in that.

Please take a few moments to seriously consider what isn't working for you right now, and what you'd like to have in your relationship(s) or your life, instead.

Most people find completing this request/preparation form to be hugely clarifying and inspiring itself. I hope it contributes to you!

What You Can Expect From Our Phone THRIVING BREAKTHROUGH Consult:

During our time together:
- I'll answer any questions you have about the primary modalities I use, including:
  - Brainspotting
  - Nonviolent/Compassionate Communication
  - Relational Neuroscience (aka Interpersonal Neurobiology, including Polyvagal Theory)
  - Attachment Theory
  - Authentic Movement/Somatic Expressing
  - Thriving Life principles and values
- I'll help you get crystal clear about where you are in regards to:
  - the challenge(s) you're dealing with and
  - where you WANT to be, instead
- I'll help you identify some key factors that have been blocking your ability to get where you want to be
- I’ll give you some powerful information and strategies to get you closer to resolving this challenge, and getting to have what you really want
- We'll decide if working together can offer you BREAKTHROUGH RESULTS in as little as 1 to 3 sessions ... because when it's a good "fit," that's what will happen. And it will begin right in the Thriving Breakthrough Consult. (If not, and I sense another person or approach would better serve you, I'll give you that referral.)
- If you're excited to work together, we'll explore the best options for you to do that, and I'll ask you when you'd like to get started.
Thriving and happiness are your birthright. It's a privilege for me to help you chart a course and begin your journey.
First Name: *
Last Name: *
E-mail
example@example.com
City: *
State/Province: *
Country: *
Phone Number: (country code=1 for USA & Canada) *

Country Code Area Code Phone Number
Please re-enter your phone number (XXX-XXX-XXXX). *
Can you receive texts at this number? *

Yes Yes, but only for special situations No
All that you share with me will be kept strictly confidential.
How did you FIRST hear about Vika or Thriving Life?

Met Vika in person From a Friend, Family Member, Neighbor, Colleague, Therapist, etc. (please specify below) Internet Search to Thriving Life Website (Google, Yahoo, Ask, etc.) Internet Search to some other site (please specify below) Thriving Village Facebook page (thrivingvillageinternational) Thriving Life Institute Facebook page Presence Practice Facebook page Meetup Group (please specify which one, below) Thriving Life email CNVC Website ORNCC Website ORNCC Newsletter Sacred Circle Dance list Other (please specify below)
If we don't already know each other, how did you find out about me? *
Have you watched any of my free videos, yet? (see http://thrivinglifenvc.org/free-videos) *

How Our "Broken Toes" Sabotage Our Relationships (this changes everything) The Secret to Happiness/NVC Overview (campy and fun!) How to Stop Saying and Doing Things You Regret Later The 3 Essential Elements of Healthy Boundaries (Surprising) Key Signs You've Lost Your Boundaries (and are in ALARM) I haven't watched any of the free videos yet
Have you participated in a THRIVING FUNDAMENTALS Workshop, or watched the Thriving Fundamentals Interactive Video yet? (with the "missed connection" demo; the stick figure characters; and the Presence-Alarm/Thriving Surviving Continuum with the green, yellow, orange, and red zones; see http://thrivinglifenvc.org/fundamentals) *

Yes, in person Yes, I watched the interactive video No, but I'm planning to I don't know / I don't currently have plans for that
1) What situation, issue, or concern are you wanting to address? *
1a) What are your biggest challenges when it comes to this situation, issue, or concern? *

1b) How satisifed or happy are you with this part of your life, right now? *

	1	2	3	4	5	6	7	8	9	10

1 is Extremely Unsatisfied/Unhappy, 10 is Extremely Satisfied/Happy

2) What have you tried so far, to address or resolve this? *
3) How did that work for you? *
4) What is not resolving this costing you? (feelings, qualities, well-being, etc.) and your outer life (circumstances, events, resources, relationships, etc.). *
5) How much longer are you willing to have things stay the way they are? By when are you committed to making sure you've created a significant change in this issue or circumstance? *
6) What do you REALLY want instead? Please be as specific and detailed as possible, addressing both your inner life (feelings, qualities, well-being, etc.) and your outer life (circumstances, events, resources, relationships, etc.). *
7) What would your life be like, if you were able to get what you want? Please be as specific and detailed as possible, addressing both your inner life (feelings, qualities, well-being, etc.) and your outer life (circumstances, events, resources, relationships, etc.). *

NOT IN USE 8a) Right now, how confident are you that you have the skill, ability, or capacity to do what you need to do, to get or create what you're hoping for?

	1	2	3	4	5	6	7	8	9	10

1 is Not at all Confident, 10 is Very Confident

8) On a scale from 1-10, how committed are you to getting what you want most, in this part of your life? *

	1	2	3	4	5	6	7	8	9	10

1 is Not At All Committed, 10 is Extremely Committed

9) Are you willing to invest some of your time, attention, energy, effort, and financial resources, to get what you REALLY want in this part of your life? NOW? (Not necessarily with me, just in general.) *

Yes, I'm totally ready to invest some of my resources and get results starting NOW I'm totally willing to invest some of my resources to get results, but I'm not sure yet if it's the right time Honestly, I just want the complimentary consult
10) What type of issue are you hoping to receive support for, if we both feel we're a good "fit" to do some work together? (Please check all that apply.)

Personal Relationship Business
10) What type of issue are you hoping to receive support for, if we both feel we're a good "fit" to do some work together? *

Personal Relationship Business A combination of 2 or 3 of these
10a) If it is a Relationship or Business issue, what is your relationship with the other person? *

Dating and considering "getting serious" in some way Current Romantic Partner Former Romantic Partner Parent Child Other Family Member Business Partner or Client (current, past, or prospective) Boss/Supervisor Coworker Neighbor Teacher Classmate Friend
11a) In what ways do you regularly take care of yourself (eating well, exercise and movement, meditation and spirituality, friends and family, alone time, enjoyable work, rest and fun/play, etc.)? *
11b) Do you make a point to give some time and attention to your self-care? *

Yes, every day Yes, 4-6 days a week Yes, 2-3 days a wek Yes, at least 1 day every week No, I'm not there yet, but I'm working on it No, I'm not there yet, but that's part of what I want to change and why I'm exploring working with you
12) What would you MOST like to get out of your THRIVING BREAKTHROUGH Consult? *
13) Are you completing this request form after receiving a special email invitation?

Yes No I'm not sure
13a) Please enter your special invitation code (all CAPS)
14) Are you able to connect by Zoom video conference (recommended), or would you like to make a special request to connect by phone?

Zoom (and I've used it before) Zoom (and I'm new to it) I request that we connect by phone, please
15) Please offer 3 to 6 times (using the PACIFIC time zone) on 2 or 3 different days during the next week, when you would be available for a 45-minute Thriving Breakthrough phone consult (between 11am and 8:30pm; all times PACIFIC, which is 3 hours earlier than Eastern/New York Time and 8 hours earlier than GMT-0/London Time. NOTE: If you require an earlier or later time, please make a specific request for that.) *
16) Is there anything else you'd like me to know? *
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Thank you for all you've shared!

I'm delighted to clarify together, what can make a powerful difference for you on your journey.

I look forward to connecting with you soon,

Vika Miller, MA
Thriving Life & Community
503-395-5366
www.thrivinglifenvc.org
www.facebook.com/thrivingvillageinternational
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