Relationship Coaching Intake Form 
Welcome to the first step towards bettering your relational life! 

Details of program: 
  • 1:1 individual coaching [no couples yet!]
  • 3 months [option to renew]
  • Meet weekly or bi-weekly [your choice]
  • 1 hour meetings
  • $95 per session
  • Pay in full or pay in parts [monthly via Paypal subscription]
  • We will discuss your desired structure during your consultation. 
The steps you take from here: 
  1. Fill out this intake form. 
  2. Book your 15 minute consultation call.
  3. If we agree to work with each other, I'll send you the final steps! [client agreement & payment]
Submission of this intake form indicates to me that you take this enrollment process seriously. 

I look forward to working with you! 
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Email *
Full name: *
Pronouns
Date of Birth
MM
/
DD
/
YYYY
Relationship status *
Sexual orientation *
Relationship style *
Length of current relationship[s] if applicable:
Do you know that you need to want on in your relationships? Or, if you are single, do you know what you want to work on in regards to love & dating? *
If you know what you want to work on, *briefly* describe what's going on:
Describe any personal growth or self-improvement efforts you've undertaken prior to relationship coaching [meditation, journaling, somatic work, coaching, therapy, etc] *
Do you have any medical conditions or mental health struggles that I should be aware of—for the sake of being able to better accommodate you:
Right now I'm unable to take evening clients. I work regular hours, 9-5pm MST Mon-Fri. Will this timeframe work for you? *
I acknowledge that Relationship Coaching is a distinct service and not a substitute for therapy. I understand that, should it become evident during our coaching relationship that the services of a therapist would be more appropriate for my needs, I will be referred to a qualified therapist to receive the support that best serves my well-being. *
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