Kingdom Dominion Coaching Intake Form

Kingdom Dominion Coaching Intake Form

ASSESSING YOUR DISCOVERY
Personal Information
Full Name*

First NameLast Name
Email Address*
Phone Number*
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Company/Organization (if applicable)
Position/Title
Business Empowered Affiliation
Are you a current BEICC Chamber Member?*

Yes (receive member discount + perks)No
Coaching Goals & Focus
What area(s) would you like to focus on? (check all that apply)*

Personal Growth & TransformationSpiritual Development & Prophetic CoachingBusiness Strategy & GrowthLeadership DevelopmentMinistry Alignment & TrainingOther
If other, please describe:
Briefly describe your primary goal(s) for coaching:*
What challenges are you currently facing that you’d like coaching to help address?*
Select Your Coaching Package

⚠️Choose the package that best fits your needs. All coaching packages require a minimum one-month commitment. Services may be canceled at any time thereafter with no further obligation.
Foundation Package – Clarity & Direction
2 - 30-minute one-on-one sessions per month
Accountability check-in
Goal discovery roadmap
💲 BEICC Members: $150/month | Non-Members: $200/month
Builder Package – Growth & Strategy
4 - 30-minute one-on-one sessions per month
Personalized growth/leadership plan
Group mastermind access
Prophetic coaching insight
💲 BEICC Members: $350/month | Non-Members: $450/month
Legacy Package – Transformation & Leadership
1 Weekly one-on-one coaching (60 minutes)
Full transformation plan + prophetic activation
Unlimited text/email support
Staff/team coaching discounts
💲 BEICC Members: $600/month | Non-Members: $750/month
Select Your Coach
Select the coach of your choice:*

Dr. Kathy AmosDr. Sandy SandersClara L. ThompsonClourice C. WintersDr. Glendora TownsendMonica N. Cable
Scheduling Preferences
Preferred Session Format*

Virtual (Zoom/Online)In-Person (if available)
Best Days/Times for Sessions
Payment & Commitment
All coaching packages require a minimum one-month commitment. After the first month, services continue on a month-to-month basis and may be canceled at any time before the next billing cycle.
Payment Method*

Credit/Debit Card (Pay Below)PayPalChamber Billing/Invoice
Agreement & Signature
Statement:*

“I understand Kingdom Dominion Coaching is designed to provide guidance, accountability, and Kingdom-based strategies to help me achieve my goals. I commit to actively participating in the coaching process.”
Signature*

Clear
Date

MonthDayYear
Date

My Products*

Foundation Package – Clarity & DirectionBEICC Members: $150/month | Non-Members: $200/month

$150.00 Select One

Builder Package – Growth & Strategy💲 BEICC Members: $350/month | Non-Members: $450/month

$350.00

Legacy Package – Transformation & Leadership💲 BEICC Members: $600/month | Non-Members: $750/month

$600.00 Select One

Enter coupon

Subtotal

$0.00

Tax

$0.00

Total

$0.00

Payment Methods

Credit Card

Afterpay

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Kingdom Dominion Coaching Intake Form

Personal Information

Business Empowered Affiliation

Coaching Goals & Focus

Select Your Coaching Package

Select Your Coach

Scheduling Preferences

Payment & Commitment

Agreement & Signature

Payment Methods