Coaching Intake Form
Please fill out this form and click submit.
Name
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Address
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Time Zone
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Eastern
Central
Mountain
Pacific
Other
Email
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This address will receive a confirmation email
Phone
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Best way to reach you.
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Please select all that apply.
Email
Texting
Phone Call
Your preferred way for conducting our coaching call:
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Please select all that apply.
By phone
By Zoom Video Conference
In Person
When is your birthday?
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Marital Status
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How long have you been married?
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Spouse's Name
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I have:
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Please select all that apply.
Young Children
Grown Children
No Children
Expecting
What else would you like me to know about your family?
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What should I know about your background or history that will help me to better support you?
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When did you become aware of your spouse's sexual brokenness?
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Please describe the level of betrayal you have suffered in your marriage?
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What betrayal trauma symptoms are most problematic for you? Please check up to 4 boxes.
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Please select all that apply.
High Anxiety
Hyper-vigilance
Withdrawal, isolation, withdrawal
Self-blame
Numbness
Negative thought, flashbacks
Sleep disturbances
Appetite disturbances
Body (headaches, tremors, panic attacks)
Stomach upset
Sadness & depression
Easily triggered
Anger outbursts
Lack of motivation and focus
Using numbing substances
Negative self-talk versus truth
I am currently getting support from:
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Please select all that apply.
Individual therapy
Couples therapy
Spiritual counsel
Faith-based recovery
12-Step Meetings
Support group
Coaching
Family
Other
What caring person(s) in your life have you leaned on for support at this difficult time?
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Who would you like to share your struggle with if you could?
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Tell me some highlights about the person you are ...personality, giftedness, strengths, what motivates you, values, dreams...whatever describes you well.
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What areas (1 to 3) would you like to make progress as we work together?
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What do you feel is standing on your way of moving forward?
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Name at least 5 self-care activities that energize you? Name more if you'd like.
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Is there anything else you'd like me to know?
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What do you need from me as your personal coach?
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You've done it!!! Every step you take is worth being celebrated! You've answered some hard questions here. Well done! I look forward to working with you towards the directions God is leading you to go! I'm curious... what are you most grateful for today?
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