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Application for Coaching with Vivien Burke
Congratulations your moving forward. You can use this form for two reasons: to show me how I can help and to take a long look at what you really, really want. Take your time these questions matter.

Sending in this form will start the process towards our working together.

Once submitted, I will personally review all your answers and a member of my team will be in touch to confirm your "Discovery Call" with me. This is a private call and is focused on you. We will explore what you want, brainstorm on how to get it, and take a look at what’s holding you back. With this Form the Discovery Call is FREE.

If you plan on doing this program with your partner, they will need to be present on this phone call. Please put their name and email address in the designated spaces below and I will send them a separate intake form that they will need to fill out before our call. I am happy to work with you alone if you prefer.

Please do NOT fill out this form and schedule an appointment if you…

- Are not willing to invest time
- The love is gone but you haven’t left
- There is physical or emotional abuse
- You are looking for dating advice
- You aren’t committed to personal growth
- Don’t want to make a financial investment

If it just can’t wait, email me at with the subject line: I WANT CHANGE and we’ll get you scheduled right away!

Congratulations this is a big step forward.

Best Viv B

NB. All answers are confidential.
Email address *
First Name *
Your answer
Surname *
Your answer
Occupation *
Your answer
If you are planning on doing this with a partner what is their full name?
Your answer
Partners Email Address
Your answer
What Social Media do you use? *
Relationship Status *
Gender - How do you Identify? *
How did you find me? *
When it comes to your sex and intimate life, what's the single biggest challenge, frustration, or problem you've been struggling with? Take your time answering these questions it's really important to get it all out. *
Your answer
What do you want in your relationship, sex and intimate life? (If you had it all your way, what would your sex life look like/feel like?)  *
Your answer
Why do you want that? And what would having that give you?  *
Your answer
If you're in a relationship, please describe what it is like. Where is it headed? If you had it all your way, what will it look like in 12 months? *
Your answer
What strategies are you currently using to work through any problems/issues/challenges and how are they working for you?  *
Your answer
How are you holding yourself back from what you really want?  *
Your answer
What do you most want to learn or achieve in our work together?  *
Your answer
Anything else you want me to know or would like taken in to consideration for our work together? *
Your answer
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