The form below will need to be filled out before we begin working with each other. Once completed, please print and bring it with you to your consultation. Please contact me with questions.

 

    Your Name (required)

    Address

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    Emergency Contact Name

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    Your Email (required)

    Birth Date

    How did you hear about us?

    Please describe your top 3 priorities that you would like to work on in coaching.

    Please list any recreational or prescription drugs you are taking including marijuana and alcohol. Please be specific about how much and how often.

    Are you under the care of a psychiatrist? If "yes" please list who and a phone number.

    By typing your name below (required) you acknowledge that you have read the services and rates page in full. You understand that coaching is not therapy and you are committed to and responsible for your growth and development. You will not hold me, this coaching practice or any associated persons or entities responsible for your experiences or results.(required)