Revive to Thrive Interest Form
Thank you for your interest in Revive to Thrive.
Note: All information gathered here is protected, and in compliance with HIPAA and all other state and federal privacy laws.
What is Revive to Thrive?
This program is designed with 18-25 year olds in mind. Your commitment of 4-6 weeks to individualized coaching will help you be on your way to reaching your goals and moving forward in the areas of life that matter most to you. Your coach is ready to get started on helping you craft your goals, create structure and accomplish what you want by holding you accountable and being your cheerleader. Get started today and let us know that you are interested in this journey by completing this form.
Part 1: Demographic Information
Please complete all fields.
Date
*
/
Month
/
Day
Year
Date
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Best method of communication
Phone
Email
Age
*
18-25 years old
25-30 years old
Over 30 years old
Sex
*
Male
Female
Other
Are you currently attending school?
Yes
No
Registered to start
How did you hear about Beautiful Minds and Revive to Thrive Coaching?
*
Referral from health provider
Referral by another program
Family/Friend
Direct Website
Online Article
Advertisement
Other
Part 2: Mental Well-Being Support
Have you been seen or treated by a mental health professional in the past year?
*
Yes
No
On and Off
Are you currently being seen or treated by a mental health professional?
*
Yes
No
On and Off
Have you ever attended group therapy or group coaching?
*
Yes
No
Back
Next
Part 3: Program Interest
Life-long transformation and healthy well-being requires commitment. How interested are you in being part of an 4-6 week engagement that will include 1 on 1 coaching sessions and connecing in person?
*
Very interested in connecting in person and 1 on 1 coaching
Somewhat interested in connecting in persoon and 1 on 1 coaching
Interested in 1 on 1 coaching only
Need more information to make a decision
If interested, are you able to attend weekly, in-person connection meetings at a fun and engaging location in Placer County?
*
Yes
No
Which method of 1 on 1 coaching sessions do you prefer?
*
In person
Virtual (Zoom)
By Phone
Any of the Above
What is the most significant life or mental health challenge you are facing at this time?
*
School/Work
Family/Relationship
Finances
Depression
Anxiety
Other
Name one goal you would like to accomplish in the next few months?
On a scale of 1 to 10 (1 being Not at all Ready and 10 being More than Ready), how ready are you to create, plan and reach your goal?
*
Not at all Ready
1
2
3
4
5
6
7
8
9
More than Ready
10
1 is Not at all Ready, 10 is More than Ready
Submit
Should be Empty: