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 Name
Last 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 team
Event/workshop
Other
Would you prefer your sessions to be...
*
In person (at our therapy room in Swadlincote)
Online (via Zoom)
A mixture of the two
Don't mind
What availability do you have for the support? Please tick the times that you are available.
*
9-12pm
12-3pm
3-5pm
5-9pm
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Is there anything else regarding your availability that would be helpful for us to know?
Would you be happy to be added to Claire's mailing list?
*
Yes please!
No, thank you
How did you hear about us?
*
Word of mouth
Recommendation from a previous client
You have been a client before
Instagram
Facebook
LinkedIn
Through your employer
Event/workshop
Other
Please tick if you are being referred through your employer.
SDDC
Other
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!
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