Request edit access
1-1 Coaching Intake Form
Coaching Services I provide:

*Life Coaching
*Men's Coaching
*Dating Coaching
*Relationship Coaching

Please fill out this form in its entirety. The more information you include the more effective our sessions can be.

At the bottom of the form you can select which coaching package to register for.

All coaching sessions are 60 minutes in duration, done in a VIDEO CALL format and will be completed via ZOOM. I will provide you with a link to join your call and your calls will recur the same time each week for the duration of your selected program.

You will receive email confirmation from me upon submission of this form which will include the link to register, all call time information, call dates and coaching agreements.


1. I respect your time you respect mine. We start and end on time. If you're more than 10 minutes late, the call will not happen nor will it be rescheduled but you will be charged for the session. If you're late but before the 10 minute cut off we will proceed with your call but you will only receive the remaining time left. I will not go over time to compensate for your lateness.

2. Everything shared on the calls is confidential.

3. If you would like a recording of the sessions that can be arranged and I will need to know this before starting the first call to set up the platform accordingly.

4. You agree to be coachable. If you're only interested in advice, I'm not the coach for you. I coach to get results, period. Results are achieved when you're coachable and trust the process.

5. All payments are completed via Paypal and you will receive your receipt for your purchase via Paypal. The receipt will be sent to the email account assigned to your Paypal account or with the email you enter with your payment details.

6. I don't offer refunds, simply because I am committed to your success and by committed to the process fully we're able to cause the results you're capable of. I trust you'll reach out with any questions prior to signing up so you feel secure and excited about your investment in our time together.

7. I don't censor myself and don't expect you to either. My style is bold and I will be direct (always with compassion) so if what I say in a call seems direct, it's meant to be. Breakthroughs happen when we challenge the shit that is holding us back. I won't be serving you if I let you play small and not call you forward into the greatest version of you possible.

8. The people I serve best are:

* Men & Women committed to transforming how they date and relate to themselves and others
*Men & Women looking to improve their romantic relationships and the overall quality of the relationships in their lives
* Women who are looking to deepen their understanding of the men in their lives
* Artists who are seeking to develop their craft and making their passion their career
* Men & Women who are struggling in their dating lives
*Men & Women looking to get more on purpose in their lives
*Men looking to develop backbone & drop the "Mr Nice Guy" persona
*Men struggling to build a healthy relationship with their shame
*Men who are notoriously under-functioners and are looking to get more in touch with their masculine energy
*Men who are looking to gain better awareness over their core emotions and develop better emotional literacy
*Men & Women looking to up level their communication habits
*Men & Women looking to learn their relational needs & learn to set boundaries
*Women who are notoriously independent, over-functioners and want to learn how to achieve optimal functioning in their relationships
* Men & Women grieving heartbreak
* Men & Women who are looking to remove any blocks they consciously or unconsciously have that is preventing them from fully connecting with their purpose and their power
*Men & Women looking to reprogram and rewire old love templates that are continuously sabotaging the healthy, true love they desire
*Men & Women constantly being drawn and attracted to emotionally unavailable men and women
*Men & Women looking to work with their insecure attachment wiring and move towards more secure functioning

9. I am here to help but we're going to have fun along the way too. Humour is important to me and as a coach I know how valuable laughter can be in the transformation process. So while there will be times where we take your transformation very seriously, there will be times where we'll also enjoy the process and introduce laughter and humour into the mix. If you're looking for an all serious all the time coach I am not your person, but if you're looking for transformation that enables you to enjoy the process and have some fun while doing it, I am your guy.

10. Your results are a direct reflection of the effort you make. I would love to be a magic maker and wave a wand and magically ensure your transformation, but it doesn't work like that. If you do the work, you'll get the results period. If you half ass it, your results will reflect the mediocre effort. I'll do my part and coach my ass off for you, I expect you to do the same and put the effort in required, do the uncomfortable things to stretch beyond your comfort zone and follow through fully. If you're someone who is committed and willing to actually do what it takes then I'm ready to work with you.


Full Name *
Your answer
Email *
Your answer
Phone Number *
Your answer
Location *
Your answer
1. Why do you want to work with ME specifically? What is it about my approach and style that resonates with you? *
Your answer
2. What is your story? In 3-5 sentences please outline where you are in your life and what is drawing you towards coaching. Feel free to include any additional details that would be relevant to our time together. *
Your answer
3. What specifically would you like to receive coaching on? *
Your answer
4. What specific result would you like to experience by the end of our coaching call/program? *
Your answer
5. Have you ever done a coaching program before? *
6. What is your preferred time for your sessions? *
7. If you chose OTHER please specify when you're available and I will email you to confirm if this time slot is possible. *
Your answer
8. If you chose Monday, Wednesday, Thursday or Friday as a workable time, please specify what your preferred call time is (all call times listed above are in PST- calculate your time zone accordingly). *
Your answer
9. Which coaching option is your preference? (bi-weekly payment plans available for options 2-4) *
Never submit passwords through Google Forms.
This form was created inside of Jamie Rea. Report Abuse - Terms of Service