Name:

Address:

Postcode:

Email:

Home Telephone:

Mobile Number:

Maiden Name:

Country of Birth:

Date of Birth (DD/MM/YYYY):

Hour of Birth:

Current Age:

Please add details where appropriate - you can leave blank any that don't apply.

Partner's Name:

Country of Birth:

Date of Birth (DD/MM/YYYY):

Hour of Birth:

Current Age:

Number of children:

Detached
Semi-detached
Terraced

Flat
Bungalow
Other

What year did you move in?

Have you made any renovations and/or has the roof been removed? If so, please detail:

Please specify the number of:

Toilets

Dining Rooms

Living Rooms

Other rooms

Garages

Please tell us about the aspects of your life you'd like to work on by selecting the appropriate boxes:

Relationships:

I am single and looking for either marriage or a committed relationship

I am already in a relationship but need improvements in it

Want improved husband/wife relationship

Suspicion of or trouble with extra marital affairs/ roaming eyes

Daughter/son relationship

Mother/father relationship

Relationships is not a problem for me right now, I just want to check the future is OK

Career and Finance

I have trouble saving money

I have trouble and I'm not making enough money

I need to have better luck

I feel stuck in a dead end job

Looking for career change or advancement

Trouble at work (ie. backstabbing)

Business is not doing well

Career and Finance is not a problem for me, I just like to make sure all is OK for my future

Health (please specify any conditions in the Additional Information area below)

I need more energy, suffer from lack of energy

I feel down and need to feel more positive

Trouble getting pregnant / suffered miscarriage

Low Sex drive

My health is fine, no help needed here

Your Situation

I have been feeling stuck in a rut for many months, I have been single for 2 years, have unsupportive friends and family, and I hate my job, I have been passed over for promotions 3 times in 4 years! Someone else less qualified always gets the job. I don’t feel good about myself, I have tried motivating myself to get out of all this but it has not worked, so I am following your advice and doing something new to get out of this mess I am in. I need change or I am going to go crazy! Please help me Angela. I look forward to your reply.