Client questionnaire

First name

Last name

In your own words, break down a specific real-world event, conversation, or environment over the last 30 days where your social anxiety or app burnout caused you the most frustration. What happened, and what did you say or do?

When you feel a social situation starting to slip or feel a 'knot in the stomach' appearing, what happens to you physically? (e.g., heart rate spikes, mind goes blank, sweating palms, or an immediate urge to find the exit door)?

Look ahead at your upcoming social calendar over the next 75 days. Is there a specific wedding, corporate function, family dinner, or real-world environment where you explicitly want to deploy your new communication mechanics with quiet composure?

On a scale of 1 to 10—where 1 is total isolation and 10 is effortless real-world connection—where would you honestly rank your current level of personal communication skills today?

To ensure your absolute privacy, is there any specific topic, past boundary line, or word phrase that you would prefer we leave entirely off the table during our private Zoom modules?"