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INQUIRY FORM

Thank you
for reaching out

This short form is designed to help me understand where you are right now, what kind of support you’re looking for, and whether my coaching services are the right fit for your current needs.

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Please answer honestly and briefly. There are no right or wrong answers.

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I will contact you by email within 24-48 hours upon receiving your inquiry, from there we will explore booking a free consultation call.

Section 1: Basic Information

Preferred Method of Contact
Did someone refer you to us?
Yes
No

Section 2: Your Current Situation

Which best describes your current stage of recovery?
Currently participating in a treatment program
Recently completed treatment (within the last 3 months)
Completed treatment within the last year
More than one year into recovery
Have not attended a formal treatment program
Other

Section 3: Life Reintegration Snapshot

How would you rate your current stress levels?
Very High
High
Moderate
Low
Very Low
How is your sleep currently?
Very Poor
Inconsistent
Fair
Good
Very Good
How supported do you feel right now?
Not supported at all
Slightly supported
Moderately supported
Well supported
Very supported
How connected do you currently feel to a sense of purpose, direction, or identity?
Not at all
Slightly
Somewhat
Mostly
Strongly

Section 4: Goals & Readiness

Section 5: Fit & Logistics

Have you worked with a coach, therapist, or support professional before?
Yes
No
Are you currently receiving support from any healthcare or mental health professionals?
Yes
No
Prefer not to say
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