Full Name *

Phone *

Email *

Preferred Contact Method *

Phone

Have you previously received therapy from any therapist in Spring Grove? *

If yes, who was the therapist?

Have you worked with a coach before? *

Briefly describe your current personal or professional context (e.g., work, relationships, personal goals): *

What are your top 3 goals for coaching? *

Are you willing to actively engage in sessions, complete exercises, and apply strategies between sessions? *

How many sessions per month are you willing to commit to? *

By checking this box, I understand that coaching is not therapy, and the Coach will not provide mental health treatment.

By checking this box, I understand that if I experience mental health concerns, I will seek professional therapy or medical support.

By checking this box, I understand that coaching outcomes depend on my effort and engagement, and I release the Coach from liability.

I understand that coaching outcomes depend on my effort and engagement, and I release the Coach from liability. *

Preferred days/times for coaching sessions: *

Do you prefer phone, video, or in-person coaching (if local)? *

Phone

Video

In-person

Is there anything else you'd like me to know before we begin? *

I will review your responses and reach out to you soon.

By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply.Reply HELP for help or STOP to opt-out.

By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, new product updates among others. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.