1:1 Coaching Application

1

Name:* This field is required.

First Name

Last Name

2

E-mail address:* This field is required.

example@example.com

3

How did you hear about me?* This field is required.

4

Please describe the biggest challenges or constraints you’re currently facing in your relationships (whether personal or professional).* This field is required.

5

If you and I were to work together and you looked back at the end of the year and said, “I'm so glad I worked with Jay,” what are the top 3 outcomes you would like to have achieved?* This field is required.

6

Please describe your personal growth path. (i.e. Have you worked with coaches or therapists in the past? Do you have any practices you engage in like yoga or meditation?)* This field is required.

7

Do any of these apply to you?* This field is required.

Have an active addiction

Have a history of trauma

Have anxiety and/or depression

Other

8

Are you currently seeing a therapist, psychologist or psychiatrist? If so, what are you in treatment for?* This field is required.

9

Provided we are a good fit for each other, when would you like to start working with me?

10

Are you interested in working together on Zoom or in coming to Ojai, CA to do a personal retreat in-person?

Zoom only

In-person only

Both

Not sure

11

In the next 3 months, are you prepared to invest $3,000 USD in your ability to leverage your nervous system and your body to help shift your mind, behavior and relationships?* This field is required.Choose all that apply

Yes

No

I'd like to know more about equity pricing

I'd be interested in working with one of Jay's associate coaches at a reduced rate

12

Check out how equity pricing works here and then provide just the number of categories you identify with below. For each category you identify with you will receive $100 off the cost of 1:1 coaching.So if you identify with 1 category, that's $100 off, 2 is $200 off, etc.

13

Please tell us how you'd like to proceed.* This field is required.

I'd like to be added to Jay's waitlist

I'd like to book an interview with a Yours Truly Associate Coach