Parent Transformation Journey Intake Form

Please take a moment to fill out the form below. Initial sessions are not able to be booked until all information is submitted.

Name *

First

Last

Email *

Partner's Name (if applicable): *

Child(ren)'s names and ages: *

Marital status: *

Single
Married
Separated/Divorced

Do you have legal custody of your children? *

Tell me a little about your children. If separated/divorced/repartnered, include who are the biological parents of the children, and who is actively involved in the parenting of the children:

Is your child/are any of your children adopted or otherwise placed in your home?

Tell me about your relationship with your partner (if applicable). How do you parent together?

Tell me about your relationship with your former partner (if applicable). How do you parent together?

What are the three most significant challenges that you are facing as a parent? *

Briefly describe your own childhood/relationship with your parents. *

What are your goals for this Transformation Journey? *

How are you familiar with Dr Vanessa's work? *

Are you able to commit to the one-year program, making time for your consultations with Dr. Vanessa and actively participating in the work? *

Yes, I am.

By checking this box, you acknowledge that Dr. Vanessa's services are consultation services, and are not therapy nor a diagnostic service. These consultations cannot be used in any legal process (i.e. divorce, custody, etc) or for any purpose other than the transformation of one's own self. *

Yes, I understand

I understand that this program is non-refundable, and that I am bound to the terms of the payment plan I select. *

Yes, I understand.

I understand that my access to this program will end on October 31, 2025. I understand further that it is my responsibility to ensure I have made optimal use of the session time, programs, and/or other offerings made available to me as part of the PTJ prior to October 31, 2025. *

Yes, I understand.