Group Recovery Intensive Registration
Summer 2023 / First Session: May 3, 2023
Full Name
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First Name
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Can you receive texts on this phone number?
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E-mail
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Confirmation Email
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Location (City/State)
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Street Address
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Other
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Can I share your information with other group members?
*
Yes! Email, Phone #, and City/State
Yes! Email Only
Yes! Phone # Only
Yes! City/State Only
No, 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
City
State / Province
Postal / Zip Code
Application
Occupation
Birthdate
*
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Month
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Day
Year
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Martial Status
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Please Select
Single/Never Married
Married
Separated
Divorced
Widowed
Do you have children?
*
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.
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Have you been coached before? What was your prior experience like?
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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?
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How would you like your life to be different one month from now? One year from now? Five years from now?
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What is getting in the way of achieving these changes or goals?
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Name 3 things in your life you are procrastinating on in your life right now.
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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?
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What are some of your concerns or insecurities about being coached?
*
Are you already a member of the private SheRecovery Community Facebook group?
*
Yes
No, please send me an invite
Are you already enrolled in SheRecovery Membership?
*
Yes, please waive my monthly fees during intensive
No, 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
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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
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