Breakthrough Session · Client Intake

Let's ignite your next level.

This isn't paperwork — it's the launchpad. The more honest and specific you are here, the more powerful our work together becomes. Success leaves clues. Let's find yours.

12 min
To complete
8
Life areas
1
Decision away
0% · let's go
ALMOST THERE — THREE FINAL STEPS
Three quick steps to complete your intake
Step 1: click Submit to Stacey to securely send your completed responses. Step 2: click Save / Print as PDF and save a copy to your device. Step 3: click Complete Your Intake to upload your saved PDF and send it to Stacey. Please complete all three steps at least 24 hours before your session.
1

Who's showing up today

The essentials so we can stay connected.

2

Your Wheel of Life

Rate each area today, gut-honest, 1 (empty) to 10 (thriving).

"Where focus goes, energy flows." — and clarity starts with an honest snapshot.

Celebration & ContributionJoy, giving, gratitude
5
Health & WellnessBody, energy, vitality
5
Mission & CareerWork, purpose, calling
5
ProductivityFocus, habits, output
5
Financial WealthMoney, security, freedom
5
Emotions & MeaningFeelings, depth, why
5
RelationshipsLove, family, connection
5
Celebration & Contribution50%
Health & Wellness50%
Mission & Career50%
Productivity50%
Financial Wealth50%
Emotions & Meaning50%
Relationships50%
A balanced wheel rolls farther. Which spoke, if raised, lifts everything else?
3

The Vibe Scale™

Emotions are data. Mark where you are — then where you're rising to.

Choose one row for where you are now (I'm Here) and one row for where you're rising to (Rising To). You can change your choice anytime.

+ High vibration
I'm hereRising to
  1. Limitlessfully alive, expansive, purpose-driven
  2. On Fireunstoppable, peak momentum
  3. Fulfilledwhole, deeply satisfied, at peace
  4. Magneticin flow, high-vibe, effortless energy
  5. Joyfullight, playful, genuinely happy
  6. Empoweredstrong, self-led, in control
  7. Inspiredcreative, hopeful, forward-looking
  8. Gratefulappreciative, open-hearted
  9. Alignedvalues and actions in sync
  10. Confidentself-trusting, capable
  11. Focusedclear, intentional, present
  12. Motivatedenergized, ready to act
  13. Steadycalm, regulated, grounded
  14. Neutralokay, coasting, emotionally flat
  15. Uneasy (Fear)anxious, uncertain, off-balance
  16. Overwhelmedscattered, pressured, too much
  17. Frustrated (Anger)irritated, reactive, tense
  18. Regretfulself-blaming, stuck in the past
  19. Sad (Sadness)heavy-hearted, low, withdrawn
  20. Defeated / Numbhopeless, shut down, disconnected
− Low vibration
4

What do you really want?

Get vivid. The clearer the target, the faster we hit it.

"Setting goals is the first step in turning the invisible into the visible."

5

Where you are right now

The starting line. No judgment — just truth.

6

The story you're telling yourself

Our beliefs become our reality. Let's find the ones running the show.

"It is in your moments of decision that your destiny is shaped."

7

What truly drives you

Every choice we make is an attempt to meet a core human need.

8

Your readiness for massive action

Knowledge is potential power. Execution is real power.

"A real decision is measured by the fact that you've taken new action. If there's no action, you haven't truly decided."

7
Committed
9

Anything else I should know

The stuff that doesn't fit in a box but matters.

10

Your declaration

The moment you decide, everything changes.

I'm all in.

I'm showing up fully, telling the truth, and taking action on my own behalf. This is my time.

ALMOST THERE — THREE FINAL STEPS
Three quick steps to complete your intake
Step 1: click Submit to Stacey to securely send your completed responses. Step 2: click Save / Print as PDF and save a copy to your device. Step 3: click Complete Your Intake to upload your saved PDF and send it to Stacey. Please complete all three steps at least 24 hours before your session.
Your responses are private and used only to prepare for your coaching. — The life you want is on the other side of this decision.