Coach Tyler Email Intake Form (4 Email Package)

Coach Tyler Email Coaching Intake Form (Four Email Package)

Intake Questionnaire

We endeavor to help you with your relationship situation. To help us help you, please take a few minutes and complete the following questions so that your Coach can be better informed before advising you via email. All of the information you provide will be kept strictly confidential.

Your Name(Required)

First Last

Your Email Address(Required)

Email Address Confirm Email Address

Are you currently seeing a licensed therapist, professional counselor, or other type of mental health professional?(Required)

Did your relationship involve violence? Are you in any physical danger? Have you been subjected to menacing/stalking or sexual assault by your relationship partner? Have you experienced suicidal thoughts in the past or present?(Required)

How old are you?(Required)

Where are you located?(Required)

Who initiated the breakup? When? What was the length of your relationship?(Required)

What actions have you already taken to get your ex back? If you could have done something different with regard to your relationship, what might that be?(Required)

Would you be potentially interested in signing up for additional email coaching assistance or a one on one coaching session (1 hour in length) to help you with any relationship complications that might arise?(Required)

Give a short summary of your situation. Please LIMIT to below 1,000 WORDS!(Required)