1:1 Coaching Application

1:1 Coaching Questionnaire

Congratulations on taking this first step towards FREEDOM! Please answer the questions below to the best of your ability so I can better understand your current situation before our session. I look forward to meeting you!
Today's Date*

MonthDayYear
Date
Personal Information
Full Name*

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

TikTokInstagramLinkedInWebsiteGoogle SearchOther
Please 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
What is your reason for seeking the support of a coach? What do you expect to gain from the coaching process?*
Have you tried changing your compulsive habits in the past? Please describe your experience*
What does a successful and meaningful life look like to you?*
What is your compulsive behavior (i.e. drinking, smoking, shopping, etc.) costing you financially per month?*

$400-$500$500-$600$600-$700More than $700Other
Where do you see yourself in 6-12 months if you DO NOT make the changes you seek?*
Please provide us with an idea of your monthly budget for private coaching sessions*
Please provide us with an idea of your monthly budget for private coaching sessions*

$400-$600$600-$800
Is there anything else you'd like me to know?*
Medical Disclaimer

This coaching is NOT aimed at any person who suffers from physical alcohol dependency. If you are (or suspect that you may be) alcohol dependent or are suffering from any other medical conditions, you must seek specific medical advice from a medical professional before reducing or stopping your alcohol intake. Depending on your previous level of alcohol consumption, the physical consequences of stopping abruptly can be very serious. If you or someone you know needs more immediate support or treatment to reduce your alcohol intake, please contact your doctor or healthcare professional.

The information provided does not replace individual medical advice, one-on-one professional therapy, or any other type of traditional support/therapy. Coaching is an additional support resource to help you make changes to improve your life.

Choose Your Session Package*

One (1) 1:1 Breakthrough Call Product Image

One (1) 1:1 Breakthrough CallPlease submit payment to book your 1:1 Breakthrough Session. All sales are final.

$199.00

"Survive the Holidays" Special Discount- Use code REBEL50 for 50% off Four (4) Coaching Sessions Product Image

"Survive the Holidays" Special Discount- Use code REBEL50 for 50% off Four (4) Coaching SessionsPlease submit payment to purchase four (4) 1:1 Coaching Sessions. All sales are final.

$1,197.00

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1:1 Coaching Questionnaire

Personal Information

Questions and Details