Share your Challenge with Dr. Nancy and Coach Ziv

Share Your Challenge!

Hi!

We're delighted you're here to share your challenging issue with us!

Rest assured, your confidentiality is fully protected. You can use first name only, even a "stage name" below, if you prefer.

We do require a valid email address so we can reach out to you if needed.

Thank you very much!




1.What's your first name?(Required.)
2.What's your best email address where we can reach out to you at if needed?(Required.)
3.What is your age group?
4.What is your gender?
5.What country do you live in?
6.Which state/province do you live in?
7.Which of the following do you practice? (you may pick more than one)
8.Please share what the challenge is that you are dealing with that you would like Dr. Nancy and Ziv to address/coach you on/offer insights on.

Please include what you feel an ideal outcome would be.(Required.)
9.What emotions are you experiencing around this challenging issue? (Please name them in a list.)(Required.)
10.What in you has made this issue difficult to resolve so far? i.e. What is your internal struggle and what makes resolving it difficult for you?(Required.)
11.Anything more you'd like Dr.Nancy and Coach Ziv to know?
12.Please type your name below as agreement that we can use your story/issue as content in the Podcast, without any name or identifying features. Without it, we will unfortunately be unable to address your issue.(Required.)
13.Please type your name below as agreement that we can use your story/issue as content in the Podcast, without any name or identifying features. Without it, we will unfortunately be unable to address your issue.

----We maintain strict confidentiality, including reserving the right to change details to further protect your identity.

----I understand and agree that input from Dr. Nancy and Coach Ziv is NOT counseling, therapy, a prescription, a treatment, or recommendation for any medical or mental health condition or diagnosis.

----I understand and agree that the input given is educational in nature, and NOT a substitute for professional evaluation or treatment of mental health issues or conditions that I may be receiving or have been recommended to receive, and is not legal advice, nor is it professional health or mental health advice or guidance.

----I understand and agree to consult my personal health provider/doctor/therapist regarding my medical or mental health treatment program and I agree that I will not make any changes in such prescribed course of treatment on the basis of the input.

----I take full responsibility for my decisions and understand that no results are promised or implied from this educational service.

---- I agree not to sue Dr. Nancy Lonsdorf, Ziv Soferman or any companies they own or are affiliated with on the basis of any input I receive from my submission to their podcast session.

----My typed name below constitutes my signature and represents a legally-binding agreement.

----If you have any questions please email us at healthoffice@drlonsdorf.com


-->Please sign in the box below by typing your name:


Thank you so much for submitting your issue, dilemma or situation for our input on the podcast!(Required.)
14.Please provide your phone number:

[So we can text message you in case we don't hear back from you by email -we know how emails can get "buried!" We will not send you any other text messages - only if you specifically sign up elsewhere with us for those.]