Surrendirt 1:1 Coaching Waitlist Signup

Coaching and Community Interest Form

I'm so glad you're here! Thanks for taking the first step in your journey by filling out this form. Once submitted, you will receive a response within 48 hours about current wait times and next steps.
Name*

First NameLast Name
Phone Number*
Format: (000) 000-0000.
What time zone are you currently in?*
E-mail*
example@example.com
How did you hear about us?*
Other
What type of coaching are you interested in? (check all that apply)*

Creative coachingSpiritual coachingLife coachingUnsure - I need more informationNone of the aboveNot interested in coaching at this time
Are you interested in learning more about the Surrendirt to Community online space, which combines monthly coaching with monthly community events such as poetry workshop and dance and movement sessions, as well as other benefits?*

YesNoMaybe
Please share a bit about yourself, what drew you to coaching or the community space, and what you hope to get out of a coaching relationship and/or the community space*
For folks interest in coaching only, please list any current supports* you have in place (therapists, coaches, healers, practitioners, community, etc.). If not interested, write "N/A"*
*Coaching is not a replacement for therapy or other healing modalities and it is important to know that you have other supports in place before beginning a coaching relationship.
The cost for coaching sessions are $135 USD for the 1.5 hour Discovery session and $90 for each 1 hour coaching session thereafter, with limited sliding scaled options available. If we both decide that we are aligned and want to begin a coaching relationship, are you able to pay the full price for your Discovery session and subsequent coaching sessions?*

YesNoUnsureNot interested in coaching at this time
By Submitting this form you're giving Surrendirt LLC permission to subscribe you to our email list as well as contact you via email or phone when space becomes available. Do you consent?*

YesAdd me to the waitlist onlyI've changed my mind, just add me to the email list (this will NOT add you to our coaching waitlist)No
For folks in Western Mass, or willing to travel, are you interested in learning about upcoming outdoor dance and movement sessions in Northampton, MA?*

YesNoUnsureLove this idea, but I don't live in and am not able to travel to Western Mass!
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Coaching and Community Interest Form