Private Client Form Let’s talk Please provide me with your information Edit | Entries | Preview | Duplicate | Delete Please enable JavaScript in your browser to complete this form.Name *FirstLastPhone *Email *Top 3 Resilience Goals:Managing EmotionsLife Purpose: Goal SettingSelf-Care; stress relief strategies, brain rest and/or food/exercise/hydration/sleepConnection; Setting Up a Strong Support Network and/or improved human connectionHealthy Thinking; Releasing doubt and judgment, embracing adaptability and opportunityPost-Trauma or Post-Abuse StressBalanced RoutineAccountability Partner; I know where I’m going and just need a good accountability coachYou may wish to work on all of these areas. Please check just your top 3 priorities. I have worked with a coach before on:If yes, did you have a good coaching experience:YesNoIf no, briefly explain why here:I have a history of: (check all that apply)AbuseNeglectUnexpected loss/griefDepressionPanicAnxiety or GADAutism, ADD, ADHD, PDDPTSD or C-PTSDChronic StressChronic PainSubstance Abuse/Pain AvoidanceExcessive WorkAny Other CommentsSubmit