Connection Call Questionnaire

Connection Call Questionnaire

Please complete all questions to the best of your ability. Thank you!
Full Name

First NameLast Name
Phone Number

Country CodeArea CodePhone Number
Email
example@example.com
Pronouns

She/HerHe/HimThey/ThemOther
If other, please specify
Age
years
Where do you live?
Please include a time zone
Why are you interested in coaching? Why now?
What other modalities or practices have you interacted with to help you reach your goals?
If you have undergone therapeutic treatment for any of the following: bi-polar/manic depression; post-traumatic stress; clinical depression; eating disorders; and/or suicide attempts, bring this up on our connection call so we can determine together if coaching is a good fit for you at this time.
What do you most want from our time together?
What are you most happy with in your life in the areas of sex, love and relationships?
What do you feel most challenged by in your life in the areas of sex, love and relationships?
Do you currently have one or more intimate relationship (husband, wife, life partner, boyfriend, girlfriend, etc.)? If so, how long have you been together? What is the quality of those relationships?
Do you have any children? If so, how many and what are their ages?
Are you ready to invest in coaching, in time, energy and financially?

Yes!I think so...NoIt depends on the time and financial commitment
What days of the week are you available? Select all that apply.

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
What times of day are you available?

MorningsAfternoonsEveningsIt depends on the day
Is there anything else you would like me to know before our call?
CONFIDENTIALITY

All the information you provide will be held securely and will not be shared with anyone outside of our coaching container, unless express permission is requested and given by you.
Should be Empty: