Touch Base from the Tub – Application Questionnaire

This isn’t just a coaching session. It’s a deep, raw, and transformational experience. To ensure this is the right space for you, please answer the following questions with full honesty. There are no right or wrong answers—just truth.

First Name

Last Name

Email *

Date of birth

Pronouns

Socials Handles

Time Zone

Which of the following describe you best

A woman seeking deeper intimacy and healing

A high-achiever struggling with safety and connection

A man who wants to create a safe space for his woman

A coach or therapist who is brilliant at guiding others but struggles with being fully seen in your own truth

Other (please specify)

Your Story & Struggles

What is currently feeling blocked, or painful in your life when it comes to intimacy, safety, connection, or visibility?

How does this struggle show up in your body? (For example: tension, numbness, overthinking, avoidance, overgiving, shutdown, keeping busy etc.)

What is the biggest fear or hesitation you have around this topic?

If we were to work together in this session, what is the ONE thing you’d want to shift?

Your Awareness of Trauma

Are you aware of any past trauma that has impacted your ability to feel safe, seen, or deeply connected?

Yes, I am fully committed and ready to invest at this level.

I need to discuss the financial aspect before making a decision.

No, I am not in a position to invest at this level right now, but I am interested in exploring a lower investment option.

What is the earliest memory you have of feeling unsafe, unseen, or disconnected? (Please explain in detail.)

Do you believe this experience still affects you today? If so, how?

Your Readiness & Commitment

Are you willing to be coached openly, vulnerably, and in real time—knowing this will be recorded and shared publicly?

Yes, I’m fully in.

I’m nervous, but I know I need this.

No, I’m not comfortable being on a public platform. (If you select this, this show is not the right fit for you.)

What is your relationship with investing in yourself and your growth?

I regularly invest in my healing and transformation.

I know I need support, but I hesitate when it comes to investing in myself.

I’ve never invested in coaching or healing before.

Have you worked with a coach or mentor before? If so, what worked/didn’t work for you?

What makes you a good fit for this experience? Why do you want this opportunity?

If selected, will you commit to showing up fully, on time, and open to the process? Yes or no if no why?

Important Note: Preparing for the Show

Once selected, you will receive a second, more detailed questionnaire.

This will help identify the exact issue/disharmony that we will work on together.

This means we won’t have to go too deep into your personal history on the show itself.

Instead, we will focus on the transformation so that you can experience a real shift, without revealing private details that you don’t want family or friends to know.

Are you willing to complete this second questionnaire in full before the show?

Yes, I understand and will complete it.

No, I am not comfortable with this process. (If you select this, you will not be eligible for the show.)

Final Acknowledgment & Agreement

This session will take place live on Zoom. Do you have a stable internet connection and a quiet, private space where you can participate fully?

Yes, I have both.

No, I do not. (If you select this, you will not be eligible for the show.)

I understand that this session will be recorded, shared on social media, and used for marketing purposes.

Yes, I fully agree.

No, I am not comfortable with this. (If you select this, you will not be eligible for the show.)

Is there anything else you’d like me to know?

Submission & Next Steps

Once you submit this application, it will be reviewed to determine if you’re a fit for the show. If selected:
✔ You will receive a second, more detailed questionnaire to help prepare for your session.
✔ You must complete and return the form before the session.
✔ You will sign the participation agreement to confirm your commitment.
✔ Your session will take place live on Zoom at a scheduled time.

Only applicants who complete both steps will be considered.

I agree to terms & conditions provided by the company.