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Appointment Time with Coach	:	30 Minutes   60 Minutes   90 Minutes
Reason Seeking Counseling	:
What Do You Wish To Accomplish?	:
Your Preferred Appointment Time	:
Have You Had Counseling Before?	:	Yes   No
If so, tell us about your experience-	:
Telephone Number You Want Called For Your Appointment	:
I have read and understood the disclaimer.	:	Yes

• Telephone Counseling Sessions Only
  
  
• We do not accept any type of health insurance.
  
  
• Clients prepay for their appointments in case research is required to address specific questions to prepare for your session.
  
  
• Medical Disclaimer: We will listen to you, talk and give you strategies to help you find answers to all your concerns. No medical advice or treatments are involved. Always consult with a physician immediately if you suspect that you are pregnant or if you have contracted a sexually transmitted disease.