Client Contact Form

Butterfly Bliss Services | ✅ Please check one:*

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Executive / Administrative Services
Individual Coaching
Team Coaching
Accounting Services
1:1 Discovery Call
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📌 Note: If you have already enrolled in an individual coaching plan, please proceed to the Individuals section.

Individuals: (complete this section)
Full Legal Name

First NameMiddle NameLast Name
Marital Status
Preferred Name (Nickname)
Address

Street Address

Street Address Line 2

CityState

Zip Code
Primary Phone Number:
Please enter a valid phone number.
Work / Secondary Phone Number:
Please enter a valid phone number.
Email
example@example.com
Preferred Contact Method:
Time-Block Preferrence:
Service Type:
Connection Details:
We’d love to know how to help — why you connected — what brings you here today?
🪪 Identification Request:
For services involving executive support, coaching, any type of agreements or secure communications, we request a valid ID. Please note that our system is secure 🔐 (encrypted uploads, password protection, secure storage).
Identification Card or Driver's License Number:
Identification Card or Driver’s License Issuing State:
Please indicate the U.S. state (or country) that issued your identification.
ID Card or License Issue Date:

MonthDayYear
Enter Date
ID Card or License Expiration Date:

MonthDayYear
Enter Date
Occupation:
Employer Name (City/State):
ICE (In Case of Emergency):

First NameLast NameTelephone #
ICE Email:
example@example.com
ICE Relationship:

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