Registration:

First Name:

Last Name:

Address:

City:

State:

Zip Code:

Email Address:

Phone Number:

What is the primary goal you wish to achieve during the coaching process?

Have you attempted to achieve this goal in the past?

What do you consider the greatest impediment in achieving this goal?

What are some other benefits of the coaching process do you hope to gain?

What are examples of significant goals you have achieved in the past?

What day and time would be convenient for your regular 45 minute session?

Please include additional comments:


Payment Terms & Conditions:

Registion Fee $125 (includes 30 minute phone session)
Personal Coaching Fee $450 per month
Business Coaching Fee $725 per month

Accepted Visa, Mastercard or PayPal
Invoicing prior to months services via email due upon receipt.
Refunds apply to last two sessions only.

Includes one 45 minutes scheduled coaching session per week and unlimited email.

Client initiates session phone calls. Postponements or cancellations must be communicated no less than 48 hours prior to a scheduled session.