New Client Intake Form Hello Beautiful, Thank you for your interest in working with me! Please complete the following questions as best as you can, and share with me as much information as you feel comfortable with to help me best understand how you are needing support. The more detail the better. **Disclaimer: filling out this form does not mean you are signing up for my program, it is strictly to help me understand you better. Your answers will not be seen by anyone other than myself** 1. Name * 1. Name First First Last Last 2. Email * Enter email Confirm 2. Email * Confirm email 3. How did you hear about Elated Woman Embodiment? (if Google, please share what you were searching for) * 4. Please tell me a little about your relationship with your husband/partner. How many kids do you have together? * 5. What initially led you to be interested in working with me? Is there a particular challenge you are facing in your marriage right now? * 6. Who/what have you turned to in the past for support in overcoming these challenges? What have you tried? (Friends, counselors, coaching, Google, books, podcasts, etc.) * 7. What do you wish things were like instead? * 8. How would you rate your emotional connection with your partner/husband? 1 2 3 4 5 6 7 8 9 10 9. How would you rate your intimate connection? 1 2 3 4 5 6 7 8 9 10 10. If one year from now the challenges that you are facing are not resolved, how might you feel about that? (2-3 sentences) * 11. Why is now the time to overcome these challenges? (1-3 sentences) * 12. What is your experience with meditation? Spirituality? * 13. How do you want to feel and where do you want to be in your life in 3-6 months? * 14. How important is it to you to make this change in your life? 1 2 3 4 5 6 7 8 9 10 15. What is one goal you would have for our time together with me as your coach? * Submit If you are human, leave this field blank. Δ
