352-205-2020
[email protected]
Coaching
Couples Coaching
Marriage, LLC
Executive Coaching
Elite Athletes
Speaking & Workshops
Leadership
Mental Wellness in the Workplace
Women’s Equity
Workshops
About Us
Press
Books
Blog
Forms
Couples Coaching
Executive Coaching
Elite Athletes
Minor — Background & History
Values Inventory
Contact
✕
Couples Coaching
"
*
" indicates required fields
Today’s date
MM slash DD slash YYYY
Client Name
First
Middle
Last
Date of Birth
Month
Day
Year
Street Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Preferred Email Address
*
Would you like to subscribe to our newsletter?
*
Yes, keep me up to date with latest news and updates.
Client's Preferred Phone
Phone Type
Cell
Home
Work
Gender
Male
Female
Non-binary
Transmasculine
Transfeminine
Something not listed above
Occupation
Employer or School (if student)
Marital status
Spouse/Partner (if applicable) and Occupation
Other family members and ages
(please note whether living in or outside of the home)
How did you learn about this practice
What presenting challenges do you want to address in couples coaching?
How do these challenges impact you as an individual and/or as a couple (emotional, cognitive, physical, sexual)?
Identify 1-3 goals you want to achieve through coaching.
What other information do you want me to know to facilitate coaching?
Acknowledgement
*
* Coaching services are not clinical therapy. If clinical services are needed, your coach will offer recommendations for separate treatment.
* You will be responsible for payment in full at the time of the visit, unless alternate arrangements are made. Venmo, Zelle, PayPal, EFT, and credit card payments are accepted. (Please indicate your preferred method on the credit card authorization form. You are asked to provide credit card information as a back up regardless of preferred method.)
* Scheduled sessions must be cancelled no less than 24 hours prior to the session time to avoid missed session charge (full session fee).
I agree to the terms above.
Signature
*
YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THESE POLICIES, AND AGREE TO ITS TERMS.
Phone
This field is for validation purposes and should be left unchanged.