Reconnection Experience Form

Reconnection Experience Form

Thank you for your interest in coaching. This form is designed to help me understand where you’re at emotionally, spiritually, and relationally so I can best support you—and so we can both discern if this is the right fit.This is not about having the perfect answers—just your honest ones. Once submitted, I’ll personally review your responses before we move forward.
Name*

First NameLast Name
Age*
Gender*

FemaleMale
Email*
example@example.com
City, State, Country*

CityState / Province

Postal / Zip CodeCountry
Marital Status*

SingleMarriedDivorcedWidow
Occupation*
Briefly describe what’s been going on emotionally, spiritually, or relationally that led you to seek coaching.*
Where do you currently feel most disconnected: with God, with yourself, or with others?*

GodYourselfWith others
What are some patterns, emotional cycles, or beliefs that keep showing up for you?*
On a scale of 1–10, how connected do you feel to: *
What have you tried so far to work through what you’re facing? (This could include prayer, counseling, ignoring it, journaling, etc.)*
What helped? What didn’t?*
What would you like to be different 3 months from now?*
Have you worked with a coach or counselor before? What was helpful or frustrating about that experience?*
Are you spiritually and emotionally ready to show up fully in a coaching process like this?*

YesNoDepends
Are you the decision maker when it comes to investing in coaching?*

Yes, I am the sole decision makerNo, I share the decision with my spouse or someone else
How do you feel about investing in a coaching experience that requires more than just a small financial commitment — but offers deep, lasting transformation?*

I’m ready for that kind of investmentI’m open, but I’d need clarity on the experience and cost before making a decisionI’m looking for something low-cost or short-term right now
Is there anything else you’d like me to know about your story or season of life right now?*
AGREEMENT/REMINDERS:

I understand that all information I entered in this form will be considered strictly confidential.

The data gathered from this form will only be used as a basis for the type of coaching the client will need.

By submitting this form, I understand this is an intake process to determine if this experience is the right fit for me. I understand this is not a guaranteed coaching spot, but will be prayerfully reviewed and followed up with next steps.
Yes, I understand and agree
How did you find out about our services?*

Social MediaReferralOther
Would you like to receive our weekly newsletter?*

YesNoI’m already signed up
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