Application for Coaching
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
*
Male
Female
Non-Binary
Other
Prefer not to say
Current Age
*
Pronouns
Back
Next
What stage of life are you currently in? (select all that apply)
*
Single, never married
Separated or divorced
Co-parenting
Widowed
Dating Casually
In a relationship
Other
What brings you to coaching at this time?(e.g., dating frustration, confidence work, recovering after a breakup, deepening self-worth, etc.)
*
How would you rate the following in your life right now?
Rows
Very Low
Low
Average
Good
High
Clarity about what you want
Confidence in your communication and boundaries
Emotional availability
Dating readiness or relationship health
Sense of peace or alignment in your daily life
Supportive social connection
What's one pattern (in dating, relationships, or within yourself) that you want to break or change?
Back
Next
What would make this coaching experience feel powerful or successful to you?
What kind of support do you feel drawn to right now?
1:1 Coaching (private & personalized)
Group Coaching (shared support & structure)
Not sure yet - I'd like guidance
Have you worked with a coach or therapist before?
Yes, coach
Yes, therapist
No
Other
Coaching is a financial and emotional investment. Are you ready to invest in support at this level?
Yes, I'm ready
Maybe - I want to learn more
Not at this time
Is there anything else you'd like me to know about your story or goals?
Lastly: How did you hear about Larissa Hill Coaching?
*
Social Media
Workshop or Event
Referral
Podcast
Website
Other
Thank you so much for sharing all of this. After you submit your application, you’ll receive an email with either next steps or an invitation to book a free 30-minute discovery call to see if we’re a good fit. You’re already taking a bold step toward a more connected, confident version of you—and I’m honored to be part of that journey.
Submit
Should be Empty: