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 quitting drinking in the past? Please describe your experience*
What does a successful and meaningful life look like to you?*
What is drinking costing you financially per month (you can include Ubers, ordering things online buying food to binge on while drinking)*

$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?*

Choose Your Session Package*

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

$199.00

Total

$0.00

1:1 Coaching Questionnaire