Midlife Rebel Coaching Program Application
Thankyou for your interest in the 1:1 Midlife Rebel Coaching Program. Please take a moment to answer the following questions. 

If you are interested in booking a Single Coaching Session please click here.
Sign in to Google to save your progress. Learn more
Full name *
Date *
MM
/
DD
/
YYYY
Email *
Phone numer *
Address (including state and country) *
What is your postal address? (if different to above)
DOB *
Give me a bit of a summary of where you're at in life, love, relationships, work...
 *
What would you most like to achieve from coaching? *
Have you worked with a coach before? (this is not a requirement to work with me!) *
Imagine you're living the life you want in 6 months time. What needs to happen to bring this vision to life?
Coaching is an investment in YOU. How do you feel about prioritising you at this time?
Which coaching package are you considering? (View packages here)
Clear selection
Payment plans are available. Is this something you might be interested in?
Clear selection
How did you find out about me?
**If you found out about me from Word of Mouth, please let me know who it was so I can thank the fabulous human!
If not already done, the next step is to schedule a time for us to speak to discuss what you're looking for and how the Midlife Rebel Coaching Program can best meet your needs. 
This is a a 30 minute complimentary, no obligation consult. 
Would you prefer this on Zoom or phone?
 *
Would you like to join the Midlife Rebel newsletter?
 *

Confidentiality

As your coach, I recognise you may have the following: future plans, business affairs, customer lists, financial information, job information, goals, personal information and other proprietary information. I will not at any time use any of this information for my benefit or disclose any information to a third party. I will also not divulge that you and I are in a coaching relationship without your permission.

Disclaimer

I acknowledge that coaching is not therapeutic in nature or intent and does not deal in health, abuse or relationship issues for which counselling or therapy might be appropriate. I will not hold Robyn Patton Life Coach in any way responsible for my experience with any of the coaching programs and practices. The client is a creative and resourceful individual and the expert in their personal and professional life - the client chooses to take action and any results of those actions are the full responsibility of the client. 

Please tick the box to agree.

 *
Required
Thankyou for completing this form. Anything else you'd like to add? 
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms