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Interest Form for Relationship and Family Private Coaching Sessions with Jessica and Jeremy Martin-Weber
The purpose of this form is to indicate that you're interested in the Coaching Sessions offered by Jessica and Jeremy Martin-Weber.
Your answers will help us determine how we can support you, including a possible free 30 minute consult.
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What is your name?
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Your answer
What's the best email to reach you?
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Your answer
What's a good way to text you? (please share your number and indicate if it's cell phone and/or WhatsApp)
Your answer
Which private coaching are you interested in? (select all that apply)
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Relationships between partners
Parenting infants, toddlers, and preschoolers
Parenting school aged children
Parenting teens
Developing a family culture of communication
Other:
Required
Please tell us a bit about yourself, your family, why you’re interested in coaching, and what you hope would be the outcome of relationship and family coaching with us.
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Your answer
Which areas of focus would you be interested in discussing in coaching sessions? (Check all that apply)
Conflict resolution
Division of responsibility
Teaching and modeling healthy communication- parenting
Developing emotional intelligence
Finding balance
Understanding and working with different personalities
Behavior as communication- parenting
Anger (Experiencing and responding to)
Understanding age appropriate behavior- parenting
Managing Sensory Overload in the family environment
Partner intimacy
Physical affection and sex
How to teach children about sex
How to teach children healthy conflict resolution
Building and maintaining intra-family connections
Parental relationships with children
Practical boundaries
Parenting for the long haul
Other
Coaching Sessions run for 50 minutes, once per week. What days and times would be best for you (and partner if applicable) to have these sessions? Please include days of the week, times, and your timezone.
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Your answer
Do you understand that as coaches, Jessica and Jeremy Martin-Weber are not licensed therapists or relationship experts in any licensed or registered capacity?
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Yes
No
We (Jessica and Jeremy) prefer to offer coaching together so our clients have the benefit of both of our feedback and support. If you have any reservations about this, could you please share what they are?
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Your answer
How soon would you be interested in starting?
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Your answer
How did you hear about our Private Coaching?
The Leaky Boob Facebook Page
The Leaky Boob Private Facebook Group
We're All Human Here Facebook Page
We're All Human Here Private Facebook Group
Referred by someone I know
From an email
Other:
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If someone referred you to our Private Coaching, please share their name with us so we can thank them and they can receive the full benefit from our referral program.
Your answer
Optional - Additional Notes: is there anything else that you would like to share with us at this time?
Your answer
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