Let’s get started. The form below may feel a bit daunting, but I assure you it will give both of us a good sense of what to expect from this program. If you prefer to skip the form, shoot me an email to set up an introductory chat. Name * First Name Last Name Pronouns Preferred start date * MM DD YYYY Email * Message * Tell me a little about yourself. How did you stumble upon Periphery? What are you hoping to get out of this? What type(s) of tech are you struggling with? * Choose as many as you like Social Media Video Games Work Communications Texting Binge Watching Online Shopping Mobile Banking Porn Wearables News (doomscrolling) Dietary Restrictions or Allergies Please list any food sensitivities or any other allergies. Musical Preferences What are you listening to these days? What was the last book you read? Any injuries or physical limitations? Postal Address * Your Periphery packages will be sent to this address. Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * All one on one sessions will be over the phone. Country (###) ### #### Thank you!
