Coaching Application Form

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Hi there! Please note: I am currently excepting only female clients for small group alcohol freedom coaching. (There is the option to add 2 private sessions to the group coaching if you are a good fit for the program.) If you are male looking for alcohol coaching, please send me an email and I will happily provide you with a referral.

Rest assured this application is completely confidential, whether we end up working together or not, so please be honest and provide me with any information you think might be helpful in determining whether we are a good fit. Thank you!
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Name:* This field is required.
First Name
Last Name
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Email* This field is required.
example@example.com
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Phone Number* This field is required.
Area Code
Phone Number
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Where do you live?* This field is required.
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Where did you hear about me?* This field is required.
My Website
Referral
My Podcast, Bite-Sized Balance
Instagram
Other Podcast
Facebook
This Naked Mind website
Other
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If you heard about me via a podcast or referred to me by someone, please provide the podcast or referral name below:
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Tell me a little about yourself (i.e. age, job/career, family situation, kids' ages - if applicable):* This field is required.
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What are you struggling the most with right now that you are eager to work on and change? (i.e. relationship with alcohol, burnout, relationships, career, other unhealthy coping mechanisms)* This field is required.
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Are you physically dependent on alcohol? (i.e. can you stop drinking without experiencing withdrawal symptoms that require medical support?) If alcohol is not a problem area for you, please indicate that in the answer field.* This field is required.
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Have you worked with a coach or therapist before? If so, what was the outcome?* This field is required.
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What would success look like for you?* This field is required.
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How are you hoping that I can help you?* This field is required.
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On a scale from 1-10, with 10 being the highest, how committed are you to reaching our goals and resolving the issues you shared on this application?* This field is required.
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Do you have any specific questions or concerns for me around coaching or my approach that I can address?* This field is required.
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Is there anything else you'd like me to know?* This field is required.
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Which one of the following applies to you?* This field is required.
I'm totally ready to invest in a group coaching package to achieve my goals.
I'm mostly ready but want to hear more about what group coaching package might be right for me based on the results I want.
A group coaching program fee will likely be out of my price range. I'm looking for a self-guided online program option.
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