Complete the intake form ~ There's nothing more thrilling and empowering than the conscious decision to change! ~ INTAKE FORM Please take a few minutes to complete the Intake form below for your FREE consultation as a new client. Your information is secure and will not be shared with others. When finished, click the "submit" button, and you will be contacted within 48-hours to schedule and confirm your appointment. Please note that there are THREE assessment sections on this form: GENERAL, RELATIONSHIP (INDIVIDUAL), and RELATIONSHIP (COUPLE). You only need to complete the section that applies to you.Name(Required) First Last Gender/Preferred Pronouns(Required) Email(Required) Best Contact Number(Required)Current Satisfaction Assessment (GENERAL) Please rate each life area below on a scale of 1-10, with 10 being the highest level of satisfaction and 1 being the lowest. This assessment will help us properly address your needs and concerns, determining the most significant areas to focus on during your sessions.Career Significant Other Finances Physical Environment Friends Education/Personal Growth Fun and Leisure Physical Health and Well Being Spirituality/Religion Emotional Health and Well Being Balance in Life Family Lifestyle Other Current Satisfaction Assessment (RELATIONSHIP COACHING - INDIVIDUAL) Please rate each relationship area below on a scale of 1-10, with 10 being the highest level of satisfaction and 1 being the lowest. This assessment will help us to properly address your needs and concerns, determining the most significant areas to focus on during your sessions. Confidence Self Esteem Sense of Value/Worth Physical Attraction Lifestyle Communication Sense of Self Personality Relationship Values Awareness of Relationship Needs Other Current Satisfaction Assessment (RELATIONSHIP COACHING - COUPLE) Please rate each relationship area below on a scale of 1-10 as a couple, with 10 being the highest level of satisfaction and 1 being the lowest. This assessment will help us to properly address your needs and concerns, determining the most significant areas to focus on during your sessions. Intimacy/Vulnerability Friendship Trust Communication Physical Intimacy/Sex Emotional Rapport Shared Resources Individual Growth Spirituality/Religion Shared Interests Fun and Leisure Family Love and Affection Other Additional QuestionsDescribe in More Detail 1 to 5 Areas You’d Most Like to Focus on.(Required)If You Could Create the Results You Desired in These 1 to 5 Areas, What Specifically Would You Like to Achieve?(Required)What Would You Have to Do or Change to Reach Your Aims by the End of Our Sessions?(Required)As Your Coach, How Can I Best Support You to Achieve Your Aims and Intentions?(Required)For more information, email [email protected]CommentsThis field is for validation purposes and should be left unchanged.
