Coaching Application Form

1

Let’s see whether I can help.

Tell me a little about what’s been happening and what you’d like to change.

Keep your answers brief and honest. You don’t need to tell your whole story or find the perfect words.

I read every application personally.

– Zachary

2

Name:* This field is required.

First Name

Last Name

3

Email* This field is required.

example@example.com

4

Are you 18 years old or older?* This field is required.

Yes

No

5

Briefly, what’s been happening, and how is it affecting your life or relationship?* This field is required.A few sentences are enough.

6

What would you most like to change through coaching?* This field is required.A few sentences are enough.

8

Where do you live?

9

How old are you?

10

Coaching is not therapy or mental-health treatment. Do any of these circumstances apply to you?* This field is required.• You have been diagnosed with generalized anxiety disorder, clinical depression, or suicidal ideation. • You are currently experiencing suicidal thoughts or a mental-health crisis.

Yes

No — none of these apply.

11

For suitability purposes, do any of the following apply to you?

12

Can you comfortably commit to the full coaching investment?* This field is required.The total investment is $5,000 USD: $2,500 when you reserve your place and $2,500 automatically one month later.

I can comfortably commit to both payments and am ready to begin if accepted.

I can comfortably afford both payments, but need some questions answered before deciding.

This investment is beyond what I can comfortably afford right now.

13

What is your profession?

14

What are you struggling with most right now?

Intrusive thoughts about my partner's past

Questions about my partner's values

Worried I'm in the wrong relationship

I know I'm in the right relationship... I just can't stop thinking about their past

Other issues

16

When thoughts about your partner's past come up, what do you actually do next? (For example: ask questions, seek reassurance, compare yourself, replay details, check social media, withdraw, argue, or try to suppress the thoughts?)

17

Roughly how much time per day are you spending thinking about this?

Less than 1 hour

1-3 hours

3-6 hours

6+ hours

18

What have you already tried?

Talking to my partner

Therapy or counseling

Online content / videos

Trying to “figure it out” myself

Other

19

Why is now the right time to address this, rather than 6–12 months from now?

20

Private coaching is not therapy or mental-health treatment. Are you currently experiencing suicidal thoughts or a mental-health crisis that requires clinical support?

Yes

No

21

Are you currently involved in professional mental-health treatment, such as therapy or psychiatry?

Yes

No

22

Please briefly describe your current treatment

23

Have you ever been physically violent with your partner?

Yes

No

24

If we both decide this is a good fit, when are you prepared to start?

Immediately

Within the next 1–2 weeks

I don’t have a clear timeline

25

For important professional and ethical reasons, I cannot work with clients who have been diagnosed with generalized anxiety disorder, clinical depression, and/or suicidal ideation. Have you ever been diagnosed with these symptoms?* This field is required.

YESNO

26

For important professional and ethical reasons, I cannot work with clients who have been diagnosed with generalized anxiety disorder, clinical depression, and/or suicidal ideation. Have you ever been diagnosed with these symptoms?

27

The total investment is $5,000 USD: $2,500 when you reserve your place and $2,500 automatically one month later. Which statement best describes you?

I can comfortably commit to both payments and am ready to begin if accepted.

I can comfortably afford both payments, but need some questions answered before deciding.

This investment is beyond what I can comfortably afford right now.

28

What questions, if any, do you have about working together? Anything else you'd like me to know?

29

If you decide to invest in one-on-one coaching, how are you hoping that I can help you?

30

Before submitting your application, please confirm:

I understand that Zachary's private coaching program starts at $5,000 USD, and if Zachary and I determine we're a good fit, I am prepared to make that investment immediately.

I'm interested in coaching, but I'm not currently prepared to make a $5,000 USD investment. I would prefer a self-directed option.

31

On a scale from 1-10, with 10 being the highest, how committed are you to reaching your goals and solving these problems?

32

Is there anything else you'd like me to know?

33

Depending on your needs, please note that an investment in a dedicated 1:1 coaching program starts in the mid-four-figures (USD). Which of the following statements applies to you?

I am financially secure, ready to commit, and eager to invest in a better future. Let's do this!

I am financially secure and eager to make an investment like this, but I have a few questions first.

I am unable to invest in 1:1 coaching. I'm looking for a self-guided option.