Let's Agree on a Couple of Things

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

To make sure we're on the same page, please click "I agree" on the following statements to indicate that you understand what to expect.

Email *

First and Last Name *

When would a call be convenient for you? *

I understand that Debra Wallace is offering coaching advice based on what has worked in her experience of sexual betrayal with the hope that it will help me as well. *

I agree

Required

I understand that I am not receiving medical, psychological, or counseling advice from Debra Wallace. *

I agree

Required

I understand that I am not receiving advice from anyone trained or certified in the medical or counseling profession. *

I agree

Required

I understand that I am not receiving a substitute for professional counseling. *

I agree

Required

I understand that I am responsible for understanding, interpreting, and applying what I hear. *

I agree

Required

I understand that I will not hold Debra Wallace, or her family, liable for how I apply what I hear, or for the results. *

I agree

Required

I understand our conversations and communications are confidential to the extent defined by the laws of the states in which each of us resides. *

I agree

Required

This form was created by Debra Wallace. Strength and Dignity, LLC

Send me a copy of my responses.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms