1:1 Coaching Application
Due to the high volume of inquiries, please complete this confidential application to help me better understand your current situation.
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
Please 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
What is your reason for seeking the support of a coach? What do you expect to gain from the coaching process?
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Have you tried quitting drinking in the past? Please describe your experience
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What does a successful and meaningful life look like to you?
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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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$400-$500
$500-$600
$600-$700
More than $700
Where do you see yourself in 6-12 months if you DO NOT make the changes you seek?
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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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Is there anything else you'd like me to know?
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Please Submit Payment
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1:1 Breakthrough Call
Please submit payment to book your 1:1 breakthrough call (if we decide to work together, this fee will be deducted from your future payment)
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99.00
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