Initial Intake

Name *

First Name Last Name
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Country
Phone Number *

Area Code Phone Number
Date of Birth *

Year Month Day
Date
What is your relationship status *

If you could choose one of the following outcomes which is the most meaningful to you? *

Better love life Increased energy and improved health Deeper spiritual connection Improved relationships with family and friends More professional success
What do you believe is your biggest obstacle to having the outcome you identified above? The more details you give us, the more we will be able to assist you. *
Briefly describe a time in your life when you successfully had this outcome in place. What was going on then and how did you know you had it? *
How long have you had this problem? *
What have you already done in the past, or recently, to try to resolve and/or overcome this situation? *
Why do you believe your past efforts have not worked for you? *
On a scale of 1-10 (10 being highly likely), how confident are you that you'll be able to turn this situation around, and reach the outcome you want within the next 90 days *
Right now I..... *

Have the financial resources to invest in myself Have access to the financial resources to invest in myself Do not have any financial resources at all and am quite happy keeping my life where it is
Gail (or someone on our coaching team), will call you at the time of your appointment. As this time has been set aside especially for you please confirm your intention to show up fully by typing this sentence in the box below, word for word. I promise I will answer my phone and give my uninterrupted time and attention for my epiphany session when my coach calls", *
Finally, if you could invite anyone, alive or dead, to have supper with you, who would you invite to your table and why? *
Once you hit submit, you will be re-directed to the booking portion of this initial intake application. Please select the preferred time for your Ephiphany Call.

You will also be added to our email marketing system "ActiveCampaign", in order to receive booking confirmations etc., but of course can easily unscubscribe yourself at any time should you wish to.
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