Operation Reclaim – Coaching Intake Form (August–September)For women veterans ready to reconnect with their purpose, body, and future.
Welcome! This short form helps me learn more about where you’re at and how I can best support you. I honor your time, your story, and your service. Everything shared here is confidential. Once submitted, you’ll hear from me within 48 hours to confirm your spot.
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Branch of Service
Date of Separation
What brought you to this coaching offer? (short paragraph)
Are you currently struggling with any of the following? (check all that apply
Feeling disconnected from myself
Depression, isolation, or anxiety
Loss of direction or identity
Difficulty navigating the VA
Addiction or over-reliance on substances
Feeling numb, emotionally flatlined
Relationship difficulties
Have You worked with a coach before?
No
Yes
Are you currently using the VA for care or services?
Yes
No
What are your biggest goals right now—personally, professionally, or otherwise?
If you had support, what would be the first thing you’d want to work on?
What do you hope to gain from these 1-on-1 sessions?
Choose a day of the week best for a 1hr call
Monday
Tuesday
Thursday
Are you open to me following up about potential participation in my future PhD research study (optional)?
Yes
No
I would need to know more about it
Is there anything else you'd like me to know? (optional)
Thank you for sharing this with me. I’ll review your form and be in touch within 48 hours. Whether you’re feeling stuck, lost, or just ready for change—you don’t have to figure it out alone. I’ve got you.— Elise
Submit
Should be Empty: