Reconnection Experience Form

Reconnection Experience Form

Thank you for your interest in coaching. This form is designed to help me understand where you’re at emotionally, spiritually, and relationally so I can best support you—and so we can both discern if this is the right fit.This is not about having the perfect answers—just your honest ones. Once submitted, I’ll personally review your responses before we move forward.
Name

First NameLast Name
Age
Gender
Email
example@example.com
City, State, Country

CityState / Province

Postal / Zip CodeCountry
Marital Status
Occupation
Briefly describe what’s been going on emotionally, spiritually, or relationally that led you to seek coaching.
Where do you currently feel most disconnected: with God, with yourself, or with others?
What are some patterns, emotional cycles, or beliefs that keep showing up for you?
On a scale of 1–10, how connected do you feel to:
What have you tried so far to work through what you’re facing? (This could include prayer, counseling, ignoring it, journaling, etc.)
What helped? What didn’t?
What would you like to be different 3 months from now?
Have you worked with a coach or counselor before? What was helpful or frustrating about that experience?
If we both agree this is a good fit, are you prepared to make a decision and get started on the call?
What amount are you prepared to invest if this feels like the right fit for you?
Are you the only financial decision-maker, or does someone else need to be part of the decision?
Is the amount you listed your monthly budget or your total budget?
AGREEMENT/REMINDERS:

I understand that all information I entered in this form will be considered strictly confidential.

The data gathered from this form will only be used as a basis for the type of coaching the client will need.

By submitting this form, I understand this is an intake process to determine if this experience is the right fit for me. I understand this is not a guaranteed coaching spot, but will be prayerfully reviewed and followed up with next steps.
How did you find out about our services?

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