Application for Coaching with Vivien Burke
Congratulations your moving forward. You can use this form for two reasons: to show me how I can help and to take a long look at what you really, really want. Take your time these questions matter.
Sending in this form will start the process towards our working together.
Once submitted, I will personally review all your answers and a member of my team will be in touch to confirm your "Discovery Call" with me. This is a private call and is focused on you. We will explore what you want, brainstorm on how to get it, and take a look at what’s holding you back. With this Form the Discovery Call is FREE.
If you plan on doing this program with your partner, they will need to be present on this phone call. Please put their name and email address in the designated spaces below and I will send them a separate intake form that they will need to fill out before our call. I am happy to work with you alone if you prefer.
Please do NOT fill out this form and schedule an appointment if you…
- Are not willing to invest time
- The love is gone but you haven’t left
- There is physical or emotional abuse
- You are looking for dating advice
- You aren’t committed to personal growth
- Don’t want to make a financial investment
If it just can’t wait, email me at
with the subject line: I WANT CHANGE and we’ll get you scheduled right away!
Congratulations this is a big step forward.
Best Viv B
NB. All answers are confidential.
If you are planning on doing this with a partner what is their full name?
Partners Email Address
What Social Media do you use?
Living with Partner
Prefer not to answer
Gender - How do you Identify?
Prefer not to say
How did you find me?
Jaiya Ma referral
When it comes to your sex and intimate life, what's the single biggest challenge, frustration, or problem you've been struggling with? Take your time answering these questions it's really important to get it all out.
What do you want in your relationship, sex and intimate life? (If you had it all your way, what would your sex life look like/feel like?)
Why do you want that? And what would having that give you?
If you're in a relationship, please describe what it is like. Where is it headed? If you had it all your way, what will it look like in 12 months?
What strategies are you currently using to work through any problems/issues/challenges and how are they working for you?
How are you holding yourself back from what you really want?
What do you most want to learn or achieve in our work together?
Anything else you want me to know or would like taken in to consideration for our work together?
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