Therapy Session Application

We Can Help Change Your Life!

Please, Fill out the form below...

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Country and Time Zone

(We are in US Pacific Time Zone)

Skype ID

If you are working with us online please enter your Skype ID.

In a nutshell describe your current situation and what you think the problem is. *

What would you like to accomplish? *

(What are you trying to do?)

What would having that goal do for you? *

(How would that benefit you?)

What's your biggest challenge in attaining your goal? *

(What's stopping you from getting what you want?)

How is not getting what you want affecting you? *

What is your biggest fear in not getting what you want? *

What is your occupation and responsibilities? *

If you had one year to live, would you be content and satisfied doing what you are doing now? *

If money and time were not an issue, what would you do? *

Have you ever been coached or consulted formally or informally? If yes, what worked when you were coached in the past? *

What are three things you would most like to change about yourself? *

How committed are you to solving your problem and making this your best year ever? (On a scale of 1 - 10 where 1 is "not at all" and 10 is "completely.") *

What do you want to make sure you get from this consultation relationship? *

What motivates you the most when you get stuck? *

Have you had any traumatic memories that cause stress or tension now? *

What do you currently use to cope with stress? *

What else have you tried before to address these issues?

How did you hear about us? *

I'd like to work with: *

Kim
Dave
Either One
Both (Together)

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