Intake Form


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Intake Form

IMPORTANT NOTE: You may use the longer intake form here or the "Short Intake Form." The longer form is used for prospective clients who might need financial assistance. As a 501(c)(3), we try to accommodate prospects who really need our help but have limited financial means. As a preliminary step, we ask that you complete our "Intake Form" so that we can evaluate whether you are an appropriate candidate for our life coaching services. If you are an appropriate candidate, we will contact you within two to three business days to schedule a free 30-minute phone consultation to introduce you to our coaching process.

Coaching services are provided by "credentialed" professionals with more than 20 years of individual professional experience in mental health and/or human services. In addition, our professionals hold multiple degrees (a minimum of bachelor's and master's) and field certifications from accredited universities within the United States.

We contract with clients frequently and provide interstate coaching services through a variety of methods, including by e-mail, instant messaging, Internet/Skype, person-to-person contact, and telephone. The length of our coaching services may vary from three months to a little over a year. Because coaching is
not the equivalent of therapy or mental health services, it is not reimbursable through insurance policies. Therefore, payment must be made by other methods, such as self-pay. Prior to the beginning of each session, we expect for clients to pre-pay half of the total fee charged for services. The balance will be due after the completion of each session. For discounts, visit Groupon or Yelp.

Full Name:


City/State/Zip Code:

E-mail Address:

Home Phone No.:

Cell Phone No.: 

Scheduling Options (Please indicate days and times you are available to meet. Use Schedules 1 and 2 to select alternate days and times.):

Schedule I: Schedule II:

Personal Information



Female Male

Marital Status:


Are you employed?:

If so, what is your occupation?:

What is your salary?

No Yes

Select the issue(s) you need help with:


Why are you seeking the services of a coach?:

Have you ever sought or are you currently receiving services from other professionals, such as psychiatrists, therapists, counselors, or psychotherapists?:

No Yes

If so, please explain.

What method(s) of coaching do you prefer?:

How will you be paying for your services? (Coaching is not reimbursable by insurance. Clients must self-pay. Also, we do not accept personal checks):


Discount Code:

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