Preparation for your first appointment
Be thoughtful in your reflection, but no need to take too long. All information is CONFIDENTIAL and will be viewed by Elaine Alpert only.

If you choose not to answer any questions, mark with N/A.

*PLEASE COMPLETE at least 24 HOURS IN ADVANCE of our first session. Thank you!

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Email *
First & Last Name *
Referred by:
Briefly describe your Work, Vocation, Hobbies (2 paragraphs max)... *
Full Address *
Cell Phone *
Name and phone of emergency contact:
Is it OK to communicate by text or WhatsApp for brief communication, or do you prefer email? Please send me a WhatsApp text to get us started if you prefer to use it. *
Date of Birth *
If you've recently worked with a coach, mentor or therapist, please briefly describe the purpose of your engagement. Is this a current relationship? *
What kind of feedback and support really works for you? What doesn't work so well? *
Elaine, here's what I'm really facing in my life right now, key issues I want you to know about... *
Bottom line, this is WHY I'm coming to you at this time... *
The shifts I want to create for myself... *
What I really yearn for, that I haven't mentioned yet... *
Tell me... Where are you doing well with self-care... and what’s missing or not working? *
As far as self-sabotage... how do you tend to get in your own way? *
At home and with family... If you live with others, how would you describe the mood of people in your home? What is affecting you at home, outside of work or school? How are you doing with your family? Describe any awarenesses, conflicts or themes about which you have concern.                                 *
What additional stressors have bearing on your resilience and well-being right now? *
What have you been learning about yourself recently? *
Anything more you want Elaine to know about you and your situation?
Will you agree to participate fully in our work together and take responsibility for your results? *
Please read and check below. Missed appointments are considered paid appointments. If you absolutely must cancel, please do so at least 24 hours prior to your session. Cancellations within 24 hours are considered paid appointments (unless ill or due to an emergency).
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THANK YOU for filling this out ... I so look forward to our time together!  
A copy of your responses will be emailed to the address you provided.
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