Intro Call Form

1

First Name* This field is required.

2

Last Name* This field is required.

3

Email* This field is required.

example@example.com

4

Instagram username* This field is required.@____________

5

Where are you from?* This field is required.Country & City

6

What are your preferred pronouns?* This field is required.she/her, he/him, they/them, etc.

7

What disability(ies) do you have? All disabilities are welcome! * This field is required.Ex: Visual disability, Deaf/HoH, Physical Disability, Wheelchair User, Learning Disability, Mental Health Disability, Neurodivergent, etc.

8

Which of these best describes your goals with your disability?* This field is required.

I want to feel proud of who I am, disability included.

I want to openly use my mobility tools and ask for accommodations without worrying about what others think about me.

I'd like to develop a deep sense of self worth and self love.

I want to set and hold healthy boundaries around my disability and my needs.

I'd like to advocate for myself with confidence and clarity when experiencing ableism.

I want to accept my disability and live in the present moment without fear of the future.

I want to consistently self-regulate challenging emotions that arise around my disability and my life.

9

What do you think may be holding you back from reaching the goals you've indicated in the last question? Be as specific as possible!* This field is required.

10

How did you come to this booking form?* This field is required.

I spoke with Charlie via social media DM's.

I came to this form via a link in bio or Charlie's website.

I came to this form via referral.

11

Are you booking this Intro Call for yourself, or on behalf of someone else?* This field is required.If you are booking for someone else, they must be aware, interested and present on the Intro Call.

For myself.

For someone else. I confirm that they are aware, and are interested in working with a Disability Coach.

12

On the following page you'll be able to schedule your Intro Call with Charlie. By completing this form, you agree to be 100% committed to your scheduled time, will arrive prepared, and in a quiet place where you can focus and be fully present.* This field is required.*Please note that we are unable to reschedule your Intro Call if you are unable to make your scheduled time.

Yes, let's do it! I'm in.