Inquiry Form

Please fill out this form as thoroughly as you can. It will help in our work together. Please email it back to me prior to our first session. If you do not choose to answer any question, please write "Do not wish to answer."

*3 low-income spaces are always reserved. Please note below in the last box if you are interested in this and more information about requirements and an application will follow. Please note that these sessions often book well in advance. Thank you.

Today's Date *

Today's Date

YYYY

Name *

Name

First Name

Last Name

Phone Number *

Email Address *

Pronoun *

Drop down box

Date of Birth *

City of Birth *

Referred By: *

Relationship Status *

Drop-down box

What do you do with your time on a typical day? *

What Brings You To inquire about working together? *

How long have you been interested in learning more about change in this area? *

What are three attributes that you like about yourself? *

What offering would you like to inquire about: *

How motivated and willing are you to engage in therapy or coaching in order to make changes in your life?

If interested in individual sessions, how would you prefer session delivery? *

Drop down box

Please select which best describes your Financial Resources: (choose the one that best fits) *

“I am seeking a solution and am willing to take action and have immediate financial resources to invest”

“I have access to financial resources to invest in and am willing to take action if it feels aligned”

“I don’t have any financial resources and I am just looking for more information.”

Current location (City and Country) *

I work with people and groups globally both in-person, via video and phone.

Is there any other information you wish to share that has not been asked about on this form? *