Free Consultation Booking Form

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Email *

Parent Name *

First and Last

Phone Number

In case we need to reach you

What is your mailing address? (to receive a welcome gift, if you begin the program) *must include street, city, state, zip-code*

Daughter's First Name *

Daughter's Age *

What are the main areas your daughter is currently struggling with or could use support in? *

Check all that apply.

Confidence/Self-Worth

Purpose and Direction

Relationships/Peer Pressure

Social Media Pressure

Body Image

Eating Issues

Mental Health (feelings of anxiety, depression, etc.)

Other:

Required

Has your daughter been formally diagnosed with any mental health condition(s)? *

Yes

If you answered "Yes" to the previous question, what condition was she diagnosed with?

Is she currently receiving professional treatment/counseling services?
*

Yes

What are you most hoping she will gain from life-coaching? *

How motivated is your daughter to experience personal and spiritual growth?

Not at all

Very motivated

How did you hear about us?

Referral

Church

Podcast

Instagram

Google search

Other:

If you selected "podcast" in the last question, which podcast did you hear about us on?

Anything else you want to share with us?

A copy of your responses will be emailed to the address you provided.

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