1:1 Coaching Application
Thank you for your interest! Due to the high volume of inquiries, please complete this short, confidential application. If you are a fit for private coaching, I'll contact you to book your complimentary breakthrough session.
Today's Date
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Month
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Day
Year
Date
Personal Information
Full Name
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First Name
Last Name
Age
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Phone Number
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E-mail
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example@example.com
Questions and Details
Where did you find me?
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TikTok
Instagram
LinkedIn
Website
Google Search
Other
Congratulations on taking this step toward freedom! Tell me what your biggest challenge is right now and why you want to change it.
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Do you have ADHD?
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Yes I have a formal diagnosis
Yes I am self diagnosed
Not sure
No
Have you worked with a Coach before?
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Yes
No
Please describe your current relationship with alcohol. How often do you drink and how much?
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Have you tried quitting drinking in the past? Have you tried AA, therapy, rehab or alcohol counseling? Please describe your experience
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What does a successful and meaningful life look like to you?
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On a scale of 1-10, how committed are you to quit drinking alcohol? Why?
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What is your annual income?
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What is drinking costing you financially per month (you can include Ubers, ordering things online when drunk or buying food to binge on)
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$300-500
$500-$600
$600-$700
More than $700
The costs of drinking don't just have to involve money. What is your drinking costing you personally, professionally, health-wise?
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How much time does your relationship with alcohol take up? How many hours a week do you lose to 1.)thinking about drinking, 2.)actively drinking and 3.)recovering from drinking?
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Where do you see yourself in 6-12 months if you DO NOT change your drinking habit?
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Is there anything else you'd like me to know?
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