Prospective Client Intake Form
Fill out this form to facilitate a free consultation. What you share with me here is your choice, and will help me to give you the best consultation possible. I look forward to hearing from you!
Request a Free Consultation
What brings you to coaching? I would love to get to know more about you, your wants, your needs, and what you are seeking from coaching. I offer a unique style of transformational coaching that draws upon multiple methodologies, giving you a multi-faceted mind, body, & spirit approach that can accelerate healing. As the coaching I offer is focused on focused on love, relationships, and empowerment, we will use embodiment practices, breathwork, meditation, integrative somatic parts work, inner child work, and processes to support emotional empowerment and a sense of worthiness.
Your First and Last Name
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First Name
Last Name
Pronouns (if you wish to share)
Email
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example@example.com
Location (City, State, Country)
Your General Availability for 1:1 Coaching Sessions (select all that apply)
Tuesdays between 6:00-9:00 p.m. Eastern time (UTC-5)
Wednesdays between 6:00-9:00 p.m. Eastern time (UTC-5)
Thursdays between 6:00-9:00 p.m. Eastern time (UTC-5)
Saturdays between 10:00 a.m. - 3:00 p.m. Eastern time (UTC-5)
Other
Prior Experience - Which of the following have you experienced before? Select all that apply.
Meditation
Yoga
Breathwork
Coaching and/or therapy
Parts work and/or Internal Family Systems therapy
Emotional Freedom Technique (EFT) - Tapping
HeartMath®️ Practices
Taoist and/or Tantric and/or Kundalini practices
Previous healing modalities: What other modalities or practices have you interacted with to help you reach your goals?
Goals for Coaching: Do any of these goals describe what you are looking for? Check all that apply:
Develop a secure attachment style
Heal from emotional pain
Recover from past relational trauma
Feel more confident, worthy, and empowered
Accept, love, and forgive myself
Let go of shame and self-judgment
Feel more emotionally balanced so that I can feel proud of how I show up in relationships
Feel more open-hearted
Receive more love
Develop a sense of confidence that I can create healthy relationships
Other
Additional Desires for Coaching: In addition to any of the goals you checked above, what else are you hoping to get through the experience?
Homework Assignments such as Daily Practices & Exercises: What is your level of ability to commit to these?
I hate homework assignments and just want to experience the coaching sessions.
I am very busy. I may be able to do 5 minute assignments.
I can probably make the time and stick to it.
Bring it on! I want all the practices I can get!
Other
Safety: What can I do/say or NOT do/say to support you in feeling safe? Is there anything you want me to know?
What is your age range?
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Please Select
Under age 18
18-25
25 or older
Acknowledgement of Use of Zoom
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I understand that coaching sessions are being offered online using the application Zoom.
Please verify that you are human
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Submit
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