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Coaching Pre-Screen

Your Name

*

Age

*

Your Email Address

*

Your Phone Number

*

How do you prefer to be contacted?

*

Email

Text Message

Phone Call

Please specify your availability for contact

*

Which area are you most interested in focusing on?

*

What dynamic are you looking for?

*

A

Bible Study

B

Christian Mentor

C

Peer Support

D

Recovery Sponsorship

What are your current obstacles?

*

Emotional Health

Mental Health

Social Health

Physical Health

Financial Health

Career Health

Spiritual Health

Environmental

Please explain:

*

Are you currently taking any prescribed medications for these issues?

*

A

Yes

B

No

C

Would rather not say

Please elaborate?

*

How many hours per week are you able to commit to the process of self-improvement?

*

Are you able to complete short daily or weekly tasks as part of your recovery and growth process?

*

A

Yes

B

No

Is there any other information about your current situation that would be helpful for us to know?

*

The information provided on this form is for our records to determine your eligibility and to help us prepare for our consultation. We will contact you within a few business days to schedule a free consultation to discuss our services and how we can support you.