Integrative Empowerment Group, PLLC      Coaching Appointment Request

***IMPORTANT*** Coaches services are not reimbursable by any insurance, Health Savings Account, or Flex Savings Account.***

To request an appointment, we will gather information below. Coach Catherine will contact you directly via email to schedule your first consultation. 

Thank you for your interest in IEG!

This Google form is HIPAA compliant and confidential.

Name (first and last) *
Legal Name (if different)
I am seeking coaching for myself at this time *
I am 18 years or older.
Email *
Is it okay to email you? *
What is your phone number? *Note our primary mode of communication is email. *
Is it okay to contact you by phone?  Select all that apply. *
Which of the following services are you interested in at this time? (select as many as apply)
In a few words, tell us what would you like to work on in coaching? *
Please describe your accessibility needs.
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