1:1 Coaching Application

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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Date
Personal Information
Full Name*

First NameLast Name
Age*
Phone Number*
E-mail*
example@example.com
Questions and Details
Where did you find me?*

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Congratulations on taking this step toward freedom! Tell me what your biggest challenge is right now and why you want to change it. *
Do you have ADHD?*

Yes I have a formal diagnosisYes I am self diagnosedNot sureNo
Have you worked with a Coach before?*

YesNo
Please describe your current relationship with alcohol. How often do you drink and how much?*
Have you tried quitting drinking in the past? Have you tried AA, therapy, rehab or alcohol counseling? Please describe your experience*
What does a successful and meaningful life look like to you?*
On a scale of 1-10, how committed are you to quit drinking alcohol? Why?*
What is your annual income?*
What is drinking costing you financially per month (you can include Ubers, ordering things online when drunk or buying food to binge on)*

$300-500$500-$600$600-$700More than $700
The costs of drinking don't just have to involve money. What is your drinking costing you personally, professionally, health-wise?*
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?*
Where do you see yourself in 6-12 months if you DO NOT change your drinking habit?*
Is there anything else you'd like me to know?*
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1:1 Coaching Application

Personal Information

Questions and Details