Integrative Empowerment Group, PLLC Coaching Appointment Request

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***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 *

Yes, I am reaching out for services for myself.

No, I am reaching out for another person.

I am 18 years or older.
*

Yes, 18 years or older.

No, under the age of 18.

Email *

Is it okay to email you? *

Yes, it is okay to email me.

No, do not email me.

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. *

Yes, phone calls are okay.

Yes, voicemails are okay.

Yes, text is okay.

No, do not contact me by phone.

Required

Which of the following services are you interested in at this time? (select as many as apply)
*

Free 15-minute initial consulation

Ongoing consultation (55-minute session) - $125 - This option is best suited for those who wish a pay-as-you-go plan.

Short-term consultation package ( 5-session package) - $600 - This option is best suited for those who wish to set up a longer series of sessions, and is paid 50% up front and 50% after two sessions.

Long-term consultation package )10-session package) - $1100 - This option is best suited for those who wish to set up a longer set of sessions, and is paid 50% up front and 50% after four sessions.

Required

In a few words, tell us what would you like to work on in coaching? *

Please describe your accessibility needs.

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