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Welcome to the next phase of your joyful life. I will do my best to help you create the changes you are seeking. I can help you more successfully if I know more about you and what led you to consider coaching. In addition to your contact information, please provide any information you think is important for me to know in order to help you.

Your Name



Your Email


Texts OK?


How did you find me?

If choosing online sessions do you prefer Skype or Google Hang Out? (required)

What are your primary goals?

Have you had coaching or counseling sessions in the past?

If so, what was the focus and how was it helpful to you?

Please check the areas you are interested in:

Stress ManagementTransitionsFinding/Enhancing CreativityLifestyle ChangesGoal Setting/RealizationImproving Overall Health

Other Goals

Anything else you think it would be helpful for me to know

By signing below you acknowledge that you have read and understood below and provided all information needed for me to provide you with appropriate guidance. You may request a receipt to submit to your insurance, but insurance will not be billed directly. You agree to pay for services at the time rendered unless otherwise discussed.


Coaching is a powerful tool for creating change in the present and developing a path toward the future. It is not counseling. My goal is to assist you in achieving a heightened sense of well-being and developing, defining and/or achieving your goals and maximizing your love of life. If your goal is to resolve deep-seated or traumatic issues, or you are experiencing debilitating anxiety or depression, I urge you to seek a counselor who can provide the appropriate psychotherapy services.

Our work can follow a variety of paths and use myriad tools. We will create your own map. I will suggest homework which will help you implement things we discuss together and speed your growth. A commitment to several sessions will help you make the changes you seek, but are not mandatory. I may ask questions designed to help with direction, but you are under no obligation to disclose anything you’re not comfortable with. Although I am not bound by state licensing regulations, your information will remain confidential unless you request that I discuss it with someone specifically, or if I am required by law to disclose it. If I learn of any current abuse taking place it will be my ethical responsibility to report it and be sure that you and others are safe.

Time is valuable to all of us. I have a 24 hour cancelation policy. If you cancel less than 24 hours prior to the session and I am able to fill your spot, there will be no charge. If I cannot fill it, or if you don’t show for your appointment you will be charged the full session fee. Thank you for your understanding and consideration.