Form
Application for Sliding Scale
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Date
-
Month
-
Day
Year
Date
What do you hope to get out of our work together?
What do you think stands in the way of you achieving your goals for coaching?
Have you ever been in therapy? If so, for how long?
Do you have any experience with mindfulness practices such as meditation, breathwork, or yoga?
Are you a member of the BIPOC or LGBTQ+ communities?
Do you have any disabilities?
Are you a single parent?
Are you a student?
What is the most challenging thing about being in relationship with you?
What is your annual household income?
What else would you like me to know about you?
Email
example@example.com
Submit
Should be Empty: