ACCELERATE COACHING INTAKE FORM

First, fill out this form

This helps me understand where you’re at, what you want to create, and how I can best support your goals.

First Name

Last Name

Email *

Phone *

City

State

Deeper Dive

Age Range

35-44
45-54
55-64
65+
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What area do you most want to see new results in? (business/income, marriage, mental/emotional health)

What industry or profession are you in?

Why now?

On a scale of 1–10, how ready are you to start making changes right now? (1 = just exploring, 10 = ready to go all in)

How committed are you to creating real change in your life right now

Yes, totally committed!
I’m thinking about it…
I’m just curious what this is about.
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Anything else you’d like me to know about you, your goals, or what’s been holding you back?

Once you hit submit, I’ll review your responses and reach out personally with next steps.

Additional Information