Client Application Form

Thank you for your interest in working together. Please take a moment to thoughtfully answer the following questions. Your responses will help ensure we are aligned for a positive and transformative experience.

Name

First Name

Last Name

Phone

(###)

###

####

Birthdate

YYYY

What services are you interested in?

Individual Sessions

Individual Intensive

Couples Sessions

Couples Intensive

What is your primary reason for seeking personal or relationship development at this time?

Please describe the specific issue(s) you would like to address.

Have you previously worked with a therapist, coach, or participated in any personal development programs?

If yes, please briefly describe your experience and what you found most valuable or challenging.

What else have you already tried to address the issues you are currently facing?

This could include personal efforts, relationship strategies, or other forms of help you've sought.

How would you describe your current emotional and relational state?

(e.g., feeling stuck, seeking growth, experiencing conflict, navigating life transitions, etc.)

What are your top three desired outcomes for our work together?

These can be personal, relational, or both.

How do you envision a successful outcome from our work together?

Describe what success looks like for you at the end of our time together.

On a scale of 0 to 10, how committed are you to making meaningful changes in your life and relationships?

0 being unsure, 10 being fully committed

How soon are you looking to begin working on your personal or relationship development?

Are you comfortable investing in regularly scheduled personal/relationship development services?

Do you have a specific monthly budget for personal or relationship development?

If yes, what is your monthly allocation

Is there anything else you believe is important for me to know ?

Client Application Form

Lindsay Brock Coulter

Contact