Sex Positive Childrearing Based in Reichian Theory - Intake Form for Parents/Caregivers

Sex Positive Childrearing Based in Reichian Theory - Intake Form for Parents/Caregivers

Please complete the information below, and I will follow up with you by email.
Name

First NameLast Name
Gender
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Marital Status
Occupation
Are you a parent/caregiver for one or more children ages 0-12?
If yes, please briefly describe ages and any areas of concern:
What are your personal goals?
What are your expectations from this coaching relationship?
AGREEMENT/REMINDERS:

I understand that all information I entered in this form will be considered strictly confidential.

The data gathered from this form will only be used as a basis for the type of coaching the client will need.
I am interested in:
prevnext( X )
1-on-1 Sessions
You will be coached individually for 50 minutes in how Reichian principles can apply to your situation and help you create a sex-positive environment for your child. These can recur as often as desired.

$65.00

Group Sessions
You will be engaged in 50-minute group sessions led by me with other parents/caregivers.

$35.00

Total

$0.00
Payment Method
How did you find out about my services?

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