Name

Email Address

What city or town do you currently live in?

How did you hear about me? How did you hear about me? Instagram Facebook Threads Referral Google Search Other

What are your current struggles or challenges when it comes to dating or a relationship?

What do you sense is the biggest roadblock for you?

What do you want most right now?

Have you worked with a coach or therapist before?

Is there anything that I have not asked you that you would like to share with me?

Lastly, this program is a retraining of your old ways of thinking and relating to yourself. In order for you to get the most out of this program, it requires your time, effort and committment to doing the weekly homework, practicing the tools and reading the resources. At this time, are you ready and willing to commit (up to) 2 hours a week (in addition to our hour coaching session) for your growth and transformation? Lastly, this program is a retraining of your old ways of thinking and relating to yourself. In order for you to get the most out of this program, it requires your time, effort and committment to doing the weekly homework, practicing the tools and reading the resources. At this time, are you ready and willing to commit (up to) 2 hours a week (in addition to our hour coaching session) for your growth and transformation? YES! I'm ready to start this coaching journey! No I'm unsure and want to talk with you more