1:1 Coaching Application

Today's Date*

Date

Full Name*

First NameLast Name

Age*

Phone Number*

Country CodeArea CodePhone Number

E-mail*

example@example.com

Where did you find me?*

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?*

Where do you see yourself in 6-12 months if you DO NOT make the changes you seek?*

Are you interested in a more focused single coaching session to address your immediate concern, or would you like to explore a longer-term coaching program to address your goals comprehensively?*

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.

Cancellation Policy

Please note that any cancellation with less than 24 hours notice and/or no shows typically incur a $50 fee.

Choose Your Session Package*

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

$199.00

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Total

$0.00

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1:1 Coaching Questionnaire

Personal Information

Questions and Details