Start Here Step 1 of 6 16% The following form will take about 15 minutes to complete. If you prefer a shorter form, or only have a few minutes, click here. Save and Continue Later Please take some time to complete the following. Please note: if you are not comfortable answering some, or you simply don’t have a response, you do not have to fill it out in its entirety. These are designed to help us both learn more about you.What Service(s) are you inquiring about?*Choose one or more services you would like help with Birth Doula Post Partum Doula Lactation Educators Car Seat Installation FASTer Way to Fat Loss Child Birth Classes ---- Specialized Pregnancy and/or Infant Loss Sleep Coaching Chiropractic Care Medical House Calls Save and Continue Later We never share or sell your information and will only contact you after you complete this formName* First Last Email Phone Save and Continue Later Part 1 - Your Story of lossYour StoryTell us more about what is currently happening in your life External SupportsExternal supports that you are currently utilizing Internal SupportsInternal supports that you are currently relying on Save and Continue Later Part 2 - Inner ReflectionStrengths, Gifts, and TalentsMy greatest strengths, gifts or talents are …DesiresWhat I want more of in my life is …Less ofWhat I want less of in my life is …MotivationsI am motivated or inspired by…Holding backWhat holds me back the most is… PeopleThe people most important to me are …BalanceA more balanced life for me would involve …EnjoymentWhat I enjoy doing most is …Whats ImportantThe most important thing in life for me is … BalanceThings I do on a regular basis to keep me physically, mentally, emotionally and spirituality balance PeaceI get a feeling of enough and inner peace from… Save and Continue Later Part 3 - Designing the Coaching Relationship The main purpose of this coaching is your wellbeing. My role is to support you holistically through the journey of loss and to provide ongoing support for your personal development and healing. Expectations from CoachingThe main thing I want out of coaching is …Expectations from the CoachWhat I most want from my coach is …I’d like to share with you what my expectations are as your coach: Being on time for the call Showing up for yourself, even when things get tough. We need darkness in order to grow. Embrace it--Don’t run from it. Contact me with concerns, questions or insights as often as needed between calls. To maintain a positive Client-Coach relationship, we both agree to the following: Everything you share on this form and in coaching sessions will remain confidential. Confidentiality might be broken if there is an imminent or likely risk of danger to self or to others, or if release of information is required by law (pursuant to valid court order or subpoena). As your Life Coach I can not provide legal, financial, or medical advice. Life Coaching is not a substitute for therapy and does not involve the diagnosis or treatment of any mental health disorder. Your decisions and actions are your sole responsibility. As a client you are fully responsible for your physical, mental and emotional well-being. I request your permission to keep a confidential record of your name, phone number or email address in order to meet the requirements for coach credentialing by the International Coach Federation www.coachfederation.org. Signature*By entering your initials in the box below, you are effectively providing your signature, indicating that you understand and agree to the terms and conditions listed above. CAPTCHANameThis field is for validation purposes and should be left unchanged. Save and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms.