Coaching Application
1-on-1
Tell me about you
Full Name:
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First Name
Last Name
Business/ Profession:
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Location:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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-
Area Code
Phone Number
E-mail:
*
How did you hear about my coaching?
Please Select
Personal referral
Speaking engagement
Web search
Social Media
Other
Please give me a brief summary of your business and/or professional situation.
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Please tell me what key challenges you face professionally.
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Please tell what key challenges you face personally (optional).
Specifically, what do you hope to gain from working with me?
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Whether we end up working 1-on-1 together or not, are you interested in joining a small coaching cohort? (This is a small group of approximately 10-15 women who meet together online.)
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Please Select
Yes
No
Maybe
Social media accounts
Please copy and paste URLs in the space provided. This is optional.
Facebook
Instagram
LinkedIn
Please understand this: I offer coaching, and consultation. I am not a trained counselor, psychologist, or mental health professional; nor can I refer you to one. If you have clinical issues, you will have to look elsewhere for help. Do you understand?
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Yes, I completely understand.
Should we agree to work together, I would like you to commit to at least four months - as we will need time to build our relationship and formulate the best plan for helping you. (I will not require 4 months payment at once. This will be on an honor system. I will take you at your word.) Do you understand?
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Yes, I completely understand.
Submit
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