Exclusive Client Intake Form

Client Intake Form

Thank you for your interest in working with me. My services are designed for individuals who are deeply committed to their personal transformation and ascension journey. This application is meant to ensure that we are in alignment before moving forward. Please answer honestly and with intention.
Full Name

First NameMiddle NameLast Name
Date

MonthDayYear
Date
Occupation/Industry
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date

MonthDayYear
E-mail
example@example.com
Phone Number
Format: (000) 000-0000.
This is my:
Phone Number
Format: (000) 000-0000.
Occupation
Current Life & Transformation Readiness

What life challenges or transformations are currently leading you to seek this work? (Check all that apply)
Type a question

Spiritual AwakeningIdentity Crisis / Loss of PurposeRelationship Difficulties / DivorceCareer Transition / Financial StrugglesShadow Work & Healing Past TraumaOther
Other:
Briefly describe your current spiritual, emotional, and mental state.
What have you tried so far in your personal development journey?(Coaching, Therapy, Meditation, Energy Work, Other)
What are your top three goals or desired outcomes from working together?
How do you most prefer to be guided?

Straightforward & To The PointSugarcoated & GentleWith Tough LoveLike An Honest BFF
On a scale of 1-10, how committed are you to your transformation?
Section 3: Alignment & Readiness
Why do you feel drawn to working with me specifically?
Have you worked with a spiritual coach, mentor, or healer before? If yes, what was your experience like?
What fears or hesitations (if any) do you have about this journey?
Do you understand that my work is highly exclusive and transformational and requires deep personal commitment?

Yes, I fully understand and I’m readyI have some concerns, but I am open to learning more.
Section 4: Next Steps

If your application is aligned, you will be invited for a private consultation to discuss your path forward. Only a select number of applicants will be accepted at any given time to ensure deep, focused transformation.
Would you like to be considered for future exclusive opportunities if this is not the right time? (Yes/No)

YesNo
Is there anything else you’d like to share before submitting your application?
By submitting this form, you acknowledge that this journey requires full commitment, honesty, and integrity.
Date

MonthDayYear
Date
Signature

Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.
Should be Empty:

Client Intake Form

Current Life & Transformation Readiness

Section 3: Alignment & Readiness

Section 4: Next Steps