Name
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First Name
Last Name
Email
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Phone
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Please share why you are interested in receiving coaching?
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**ALL INFORMATION IN THIS FORM IS KEPT PRIVATE AND CONFIDENTIAL**
Please add as many details you feel are relevant.
What has been your experience with coaching and/or personal development in the last 24 months?
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Please share more about your main concern/issue that you want support with.
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What is your vision of who you want to be? How do you want your life to feel? How would your life be different if you fully stepped into being the person that you envision?
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Please include if there are any specific blocks you feel are present in your life right now.
Is there anything else you would like me to know about your history past or present?
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Are you financially ready and able to invest in yourself for private coaching?
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Are you currently taking any prescription medications?
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If yes, please list all medications you are currently taking.
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Are you currently under the care of a mental or behavioral health care practitioner?
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Including licensed therapist, psychiatrist, etc.
Are you currently in a dangerous or life-threatening situation?
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This includes domestic violence, abuse, stalking, coercion, current trauma, and/or other such behaviors.
What do you believe is holding you back from your life feeling like your dream life?
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Some of these may include thoughts, feelings, circumstances, or habits that you recognize as limiting but you don't know how to change them.
Do you currently have any health conditions or medical history that has felt traumatic or that you feel you need to share?
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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.