APPLICATION FOR COACHING

Thank you for your interest in working with me. I’m excited to get to know you better, and for the opportunity to help you with any and all of your dating, mating, and relating questions.

Please note, this free discovery call is to determine if working with a coach is right for you and if you’re a good fit for one of my paid programs. If after reading your questionnaire I don’t believe we are a fit, I will write to you in advance of the call.

In order for us to have a productive & helpful conversation, please take a few minutes to fill out the form below.

The more details you can give me, the better I am able to help you. (Note: all information you provide is held in the strictest of confidence and will not be shared with any 3rd party.)

Once you’ve filled out the questionnaire, you’ll be redirected to my scheduling app, where you can choose a time for our call that is convenient for you. Time slots are listed as 30 minutes for scheduling purposes, and your actual call length may vary between 15-25 minutes.

Looking forward to connecting with you.

Schedule a Coaching Call

Your Name *

Your Email Address *

Cell Phone Number *

If outside the US, you must include a Skype or WhatsApp number

City/State/Country Where You Live *

What is your age? *

Do you have children? If so, what are their ages/gender? *

Lifestyle Question: What is your annual income? *

Under $40,000

$41,000 to $70,000

$71,000 to $100,000

$101,000 to $150,000

Over $151,000

Lifestyle Question: What is your occupation and job title? *

What's your current relationship status? *

Never Married

Divorced

Widowed

Separated

Are you currently dating someone or in a relationship? *

Yes

No

What issues are you currently facing in your relationship that you need help with? *

When was your last relationship and why and how did it end? *

What if any work have you done in the area of personal growth, such as other coaching, reading self-help books. etc? *

What's your burning question for today? *

What do you feel has prevented you from finding lasting love or relationship success at this time? *

When you're in a relationship, what are your biggest fears and insecurities? *

What beliefs do you have about yourself that limit your thinking as to what's available to you in a relationship (e.g. there are no good men out there)? *

What are the two things you'd like to learn from a dating and relationship coach? *

Are you currently on one or more dating sites?

Yes

No

List the sites you use. *

Where and when did you find me? *

Right now... *

I understand that coaching requires a minimum investment of $3,000, and I have the financial resources to hire a coach.

I understand that coaching requires a significant investment, and I can find the financial resources to hire a coach.

I do not have the resources to invest in coaching.

Why should I consider taking you on as a client right now? (What makes you coachable?) *

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I'd love to have a better sense of who you are, and a photo can help. Feel free to upload a headshot if you like.

If you are human, leave this field blank.

Client Testimonial