EGI - Application - Bianca J Empowerment

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I'm so glad you're here. Please share a bit about yourself so I can prepare for our conversation.

Your Name*

First Last

Preferred Method of Contact

Your Email Address*

Email Address Confirm Email Address

Your Phone*

So I can reach you if needed. Include country code (e.g., +44, +27, +1)

Where are you located?

This helps me understand time zones and cultural context.

City Country

I know this can be difficult to talk about. Share only what feels comfortable. There are no wrong answers here.

Have you experienced pregnancy loss (miscarriage, stillbirth, ectopic pregnancy, TFMR, infant loss)?*

Yes

Prefer not to say at this time

How long ago was your most recent loss?

There's no "right" timeline for this work. I'm just getting a sense of where you are.

What's bringing you to this coaching programme right now?*

This helps me understand what you're hoping will shift.

The Empowered Grief Intensive Application Form