Client Intake Form

Name *

First Name

Last Name

Phone *

(###)

###

####

Birth Date *

MM

DD

YYYY

Spouse name

if applicable

First Name

Last Name

Are you financially ready and able to invest in yourself for private coaching? *

YES! I'm ready and sure! Sign me up!

Yes, I think I can make it happen, but it's a stretch for me.

Right now I am in financial stress but would like to explore options.

Are you currently under the care of a mental or behavioral health care practitioner? *

Including licensed therapist, psychiatrist, etc

YES

NO

Are you currently taking any prescriptions for mental or behavioral health medications? *

YES

NO

Are you currently in a dangerous or life-threatening situation? *

This includes domestic violence, abuse, stalking, coercion, current trauma, and/or other such behaviors.

YES

NO

After your application is reviewed, what is your preferred method of communication for notifications? *

Applications are reviewed thoroughly and responses sent within 3 business days.

Email me!

Text Please.