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.CareerSignificant OtherFinancesPhysical EnvironmentFriendsEducation/Personal GrowthFun and LeisurePhysical Health and Well BeingSpirituality/ReligionEmotional Health and Well BeingBalance in LifeFamilyLifestyleOtherCurrent 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. ConfidenceSelf EsteemSense of Value/WorthPhysical AttractionLifestyleCommunicationSense of SelfPersonalityRelationship ValuesAwareness of Relationship NeedsOtherCurrent 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/VulnerabilityFriendshipTrustCommunicationPhysical Intimacy/SexEmotional RapportShared ResourcesIndividual GrowthSpirituality/ReligionShared InterestsFun and LeisureFamilyLove and AffectionOtherAdditional 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.