The Reclamation Coach Application
Regulate. Rewire. Reclaim.
Full Name
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First Name
Last Name
Best Email Address
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example@example.com
Instagram handle and/or phone number
Age
Occupation
Preferred Contact Method: enter below (email/text/IG/etc)
What brings you here right now?
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I’ve recently gone through a painful breakup or destabilizing emotional experience
I feel stuck in patterns that I can't seem to break on my own
I've been through a lot and I'm ready to turn that pain into power
I know I'm meant for more but something keeps holding me back
I want to call in secure love, wealth, and/or purpose
Other or combination of the above
Elaborate on what brings you here & how long it's been going on for
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What have you already tried to heal or move forward?
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Therapy
Journaling / self-help work
Talking to friends / support groups
Time / distraction
Coaching or courses
Nothing has really helped yet
If you had a magic wand, what would the outcome be in the next 3-6 months?
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On a scale of 1–10, how ready are you to fully let go of what’s been keeping you stuck and invest in your healing and next-level identity?
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1 (not ready)
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2
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10 (all in)
10
1 is 1 (not ready), 10 is 10 (all in)
Coaching is an investment in your transformation. My 1:1 container options are 3 months for either $2997, $3997, or $4997 depending on how much 1:1 support you want. You can pay in full or there are payment plan options for that you can stretch over 24 months. Which option is best for you right now?
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Buy Now Pay Later Option
Flexible monthly payment option for coaching
$150
$
150
Quantity
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Pay in Full Option
$2,997
$
2,997
Quantity
1
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10
Why do you feel called to work with me specifically? (What about my message, coaching, or approach resonated most with you?)
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Anything else you'd like me to know?
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Are you ready to book your breakthrough call and take the leap toward reclaiming your power and taking your life back?
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Yes, I'm ready
No, I'm not ready
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