First Name
*
Last Name
*
Phone
Email
*
Which program are you most interested in?
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RiseAbove(TM)
ThriveBeyond(R)
What is the main challenge you are facing right now?
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What has led you to consider coaching at this stage of your life?
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What would you like to change or improve over the next 3–6 months?
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Have you previously worked with a coach, counsellor, or therapist?
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Yes
No
Prefer not to say
How ready do you feel to commit to personal growth and deeper support?
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100% ready
Mostly ready
Unsure
Not ready yet
What timeframe are you hoping to begin support?
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As soon as possible
Within 1 month
Within 3 months
Just exploring for now
In your own words, what would make this coaching experience feel meaningful or successful for you?
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Is there anything you’d like me to know before we connect?
*
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