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Is there a part of you that feels stuck or in pain, something that’s been pulling you off course or getting in the way? How would you describe it?

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First Name *

First Name

Last Name *

Last Name

Email Address *

Phone Number *

What does this part tend to do—or stop you from doing?

(For example: overthink, withdraw, shut down, lash out, stay silent, avoid things, try to keep everyone happy, etc.)

What kinds of thoughts or beliefs come up when this part is active? *

(Like: “I’m not enough,” “I’ll mess this up,” “People will leave,” “I have to hold it all together,” etc.)

What emotions show up when you’re in this part?

(Such as: sadness, fear, anger, shame, guilt, numbness, overwhelm, etc.)

Do you feel this part in your body? If so, where and how?

(Maybe it feels like tightness in your chest, pressure in your head, tension in your shoulders, heaviness in your stomach—anything you notice.)

What do you sense this part is trying to protect you from—or help you with?

(There’s no wrong answer. Just go with your gut. Even if it’s just a guess.)

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