Client Intake Please complete the form below. All information is confidential. Name(required) Email(required) Phone(required) Web Site Mailing Address(required) Birthdate (mm/dd/yy)(required) Have you worked with a coach or therapist in the past? If so, briefly describe your experience. Where are you currently stuck, frustrated, overwhelmed, conflicted, confused, etc..?(required) What, specifically, would you like to work on in our sessions together?(required) If we were having this discussion three years from today, and you were looking back over those three years, what has to have happened in your life, both personally and professionally, for you to feel happy with your progress?(required) What are your demographics?: Relationship status, career, religious affiliation (if any), etc. And is there anything else you'd like me to know before we begin?(required) Do you have any questions for me before we get started? Thank you.