Enquiry Form for website

Enquiry Form

To help us assess which service is most suitable for you, please complete the form below as fully as possible.
Date enquired
Date of Birth*
Name*

First NameLast Name
Telephone Number*
Email*
Area you live in*
Profession*
What challenges are you currently facing in your life and/or business at the moment that you would like support with? *
Please tell us what you are hoping to get out of the support? *
Have you received support previously? *
Which services are you particularly interested in?*

Coaching (with Claire)Time Line Therapy (1/2 day with Claire)Destiny Mapping (1/2 day values coaching with Claire)Accelerated Breakthrough Method (1:1 intensive day with Claire)Hypnotherapy/NLP (with Claire)Counselling with one of Claire's teamEvent/workshopOther
Would you prefer your sessions to be...*

In person (at our therapy room in Swadlincote)Online (via Zoom)A mixture of the twoDon't mind

What availability do you have for the support? Please tick the times that you are available.*

Is there anything else regarding your availability that would be helpful for us to know?
Newsletter*

Yes, subscribe me to this newsletter.
How did you hear about us?*

Word of mouthRecommendation from a previous clientYou have been a client beforeInstagramFacebookLinkedInThrough your employerEvent/workshopOther
Please tick if you are being referred through your employer.

SDDCOther
Thank you for completing this. We'll be in touch within the next 48 hours via email to explore the next steps with you. Please remember to check your junk!
Should be Empty:

Enquiry Form