Client Intake Form

New Client
Welcome!
I'm so excited to begin our partnership!! To ensure I have the information I need to best serve you, please take a few moments to fill out the form below. If you have any questions, please feel free to contact me at any time. Thank you!
Contact Information
CLIENT

First NameLast Name
ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
EMAIL
example@example.com
PHONE NUMBER
Please enter a valid phone number.
PREFERRED PRONOUNS

She/HerHe/HimThey/ThemOther
PREFERRED CONTACT METHOD

PhoneEmailTextInstant MessageOther

New Client
How did you hear about my coaching services?
What was your motivation to seek coaching at this time?
Please share a little bit about your family and your connection to the LGBTQ community.
Goals and Expectations
What specific goals do you hope to achieve through coaching?
Are there particular challenges that you are currently facing that you want to address?
How would you describe the ideal outcome of our coaching sessions?
Understanding and Awareness
How would you rate your current understanding of LGBTQ issues? (Beginner, Intermediate, Advanced)
Are there specific topics or areas that you are eager to learn more about?
Support Systems
Do you have any support systems in place such as community groups, family, friends?
How can these support systems be improved or enhanced?
Practical Details
What is your preferred method of coaching sessions? (Weekly, Bi-weekly, Monthly)
Are there specific days and times that work best for you?
Coaching Options

One (1) 60-minute session - $200Three (3) 60-minute sessions - $500Five (5) 60-minute sessions - $750
Additional Information
Is there anything else about your situation or needs that you would like to share?
Do you have any concerns or questions for me at this stage??
Should be Empty:

New Client