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Name

First Name

Last Name

Phone Number

How would you like to work with Melissa?

You can select more than one option.

Therapy

Breathwork

Supervision

Zenso Mastery (1:1)

Zenso Minimind (GROUP COACHING)

What are the 3 biggest challenges in your life right now?

(What’s weighing you down right now? Share the top three challenges you’re facing?)

Why are you specifically interested in working with Melissa?

Would you consider working with another clinician if they had availability sooner than Melissa?

How did you hear about Melissa?

How motivated are you to do the work required to improve your life?

What previous experiences, if any, have you had with therapy, coaching, or breathwork?

Do you have any urgent risk issues that would make waiting for an appointment with Melissa unsuitable, such as suicidality, serious self-harm, or intent to harm another person? If this is the case, please contact 000 or 1300 MH CALL immediately. Your safety comes first.

come & say hello

~

come & say hello ~

SHOP 9

17 HARVEST COURT

SOUTHPORT QLD 4215

(07) 5627 0551

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We acknowledge and express our deep gratitude to the Aboriginal and Torres Strait Islander Peoples as the traditional custodians of this land and its waters. Zenso House stands on the lands of the Kombumerri People. We pay our respects and honor their Elders—past, present, and emerging

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