JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Free Yourself from Religious-Shame, BUILD
Confidence
, and Make
Friends
Let's set up a short ten-minute call to see if and how I can help you!
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Name
*
Your answer
Preferred name (if different)
Your answer
Email
*
Your answer
Phone number
*
Your answer
Time Zone (This will help us in scheduling a call)
PST
MST
CST
EST
Other:
Clear selection
Where did you find out about our Shame-Free program?
*
Instagram Ad
Instagram page (not an ad, but Eric's page)
Facebook Ad
YouTube
Other:
What are you currently struggling with?
*
I'm lonely and alone. I have no friends or community.
I'm constantly worried about what other people are thinking of me.
I always think something bad is going to happen.
I'm just not happy, and I'm tired of it.
Even if I know being gay is ok in my head, I can't shake the belief that it's wrong, and that scares me!
I feel like a failure, like I'm never enough.
Other:
Required
Is working on removing these barriers a priority for you at this point in your life?
*
Yes, this is a priority. I need a change, and I'm willing to put in the work!
No, this is not a priority right now.
If we were having a conversation in 3 months from now, after you finish the 10-week program, what would your life look like then?
*
Your answer
Have you ever worked with a Life Coach before?
*
Yep!
Nope!
What's a Life Coach??
Other:
Working on yourself is a valuable investment! Are you willing (and able) to invest in yourself?
Yes - I have the financial means to invest in myself.
Yes - If I feel this is what I need, I'm willing to do whatever it takes to invest in myself.
No - I don't have the financial resources and I'm unable to invest in myself at this time.
Clear selection
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Life Coaching by Feltes.
Does this form look suspicious?
Report
Forms
Help and feedback
Contact form owner
Help Forms improve
Report