2023 Group Coaching Application

Group Recovery Intensive Registration

Summer 2023 / First Session: May 3, 2023
Full Name*

First NameLast Name
Phone Number*
Format: (000) 000-0000.
YesNo
E-mail*

Confirmation Emailexample@example.com
Location (City/State)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Yes! Email, Phone #, and City/StateYes! Email OnlyYes! Phone # OnlyYes! City/State OnlyNo, I will share with the group when I am more comfortable later
Address to ship paperback workbooks (ships to United States only)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Application
Occupation
Birthdate*

MonthDayYear
Martial Status*
Yes, and they live with me.Yes, but they don't live with me.No
Briefly describe your life story to date. Share as little or as much background information as you would like. *
Please briefly describe why you are seeking coaching services and what you hope to achieve? Please be as specific as you can.*
Have you been coached before? What was your prior experience like?*
Are you now or have you ever been in counseling or therapy? If yes, please explain.*
Describe your faith. What is your relationship with God like? In what ways do you sense He might be challenging you, nudging you, or trying to get your attention?*
What are some major things happening in your life right now?*
How would you like your life to be different one month from now? One year from now? Five years from now?*
What is getting in the way of achieving these changes or goals?*
Name 3 things in your life you are procrastinating on in your life right now.*
If we worked together, in what ways might you sabotage me as your coach or your own success? In what ways can I help you to not do this? *
What are some of your concerns or insecurities about being coached?*
YesNo, please send me an invite
Yes, please waive my monthly fees during intensiveNo, please send me the details
Is there anything else you would like to add?
Terms & Agreement

By submitting this application you are agreeing to the following terms. Please read carefully and check the box to agree to the terms.
- I understand that Crystal Renaud Day is a masters level pastoral counselor and certified coach, but is not a licensed counselor
- I understand Crystal Renaud Day holds no responsibility for any harm I may cause to myself or others
- I understand that Crystal Renaud Day will assign homework and failure to complete homework could result in termination of remaining coaching sessions without refund
- I understand that if I am unable to complete pre-paid coaching sessions, no refund will be provided. If extenuating circumstances apply, they will be considered on a case by case basis.
- I understand that if I miss more than two group sessions without notice, I will forfeit my place in the group without refund.
- I understand that a lack of communication with Crystal on my part (i.e. not responding to emails and texts and/or not showing up to sessions) will be interpretted as a withdrawal from group and no refund will be provided.
- I understand that each group coaching session will be 75 minutes in length and on a pre-determined date and time. I also understand that being late to a group session will cut into the total session length and will impact other group members' time as well.
- I understand that each one-on-one coaching session will 30-minutes and on a specific date and time as scheduled by me. Being late to the session will cut into my total session length. I also understand that these sessions expire on July 14, 2023.
- I understand that coaching is a confidential relationship and Crystal agrees to keep all information strictly confidential, except in situations that violate the law or harm to self or others is disclosed
Payment & Payment Plans

Choose Coaching Payment Plan*

Weekly Payment Plan

$110 due now. Then $80 per week for 11 weeks starting Week 2, April 19, 2023.

$110.00

3-Month Payment Plan

Month 1 due now. Months 2 & 3 due May 10, 2023 and June 7, 2023.

$330.00

Pay in Full

Payment due in full now.

$990.00

Enter coupon

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Expiration

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Group Recovery Intensive Registration

Application

Terms & Agreement

Payment & Payment Plans