Interest Form

Interest Form

Life Coach + Self Discovery Support
Name:*

First NameLast Name
Pronouns:*
Date of Birth*

MonthDayYear
Date
Gender Identity*

MaleFemaleNon-BinaryTransgenderUnsure/QuestioningOther
Sexual Orientation*

StraightBisexualGayLesbianPansexualDemisexualAsexualUnsure/QuestioningOther
My primary love language is:*

Words of affirmationQuality timeReceiving giftsActs of servicePhysical touchUnsure
Phone Number*
Email*
example@example.com
Relational Status*

SingleMarriedDivorcedWidowedOther
Occupation*
Do you have any mental or physical health conditions that you would like to share?*

YesNo
If yes, then please share them below:*
What are your personal goals? *
What are your professional goals?*
What changes would you like to make in your life right now?*
Describe the barriers you are currently facing in terms of your personal/professional well-being or success.*
Describe what is going well for you right now.*
What motivates you in life?*
Talk about your experience with holding yourself accountable. The good/bad/ugly.*
What are your personal strengths?*
What are your hopes for coaching?*
This is a space to share anything else that feels important :)
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 understand that in order to be successful, it is vital to follow the plan agreed by both the life coach and the client.
Life Coach Plan Options*
prevnext( X )
1 Month of Free CoachingYou will be coached 1 session per week for 4 consecutive weeks. * accepting 2 clients only *
$ Free



Sliding Scale SessionsFolks experiencing financial challenges are welcome to a $25 minimum price per session. If you can afford more, please pay what you can. * accepting 2 clients only *
$25.00



Weekly SessionsYou will be coached every week. Minimum of 8 Weeks.
$80.00 Number of Weeks



Two SessionsYou will be coached for two sessions.
$100.00



Five SessionsYou will be coached for five sessions.
$200.00



Total

$0.00
Payment Method*
Should be Empty: