New Client Intake Form

Focus your mind and get your life back on track

Rekindle Relationships is happy to welcome you as a new client. We are excited that you chose us to help you achieve your personal goals. Please complete the following information and submit it so we can get started.

Contact Form Demo (#2)

First Name

Last Name

Please Select Your Service Type

Date of Session

How frequently would you like your sessions?

Gender and Preferred Pronouns

DOB

Marital Status

Education Level

Email

Permission

I provide Rekindle Relationships with permission to communicate with me via email to receive updates, etc.

Primary Cell #

Can Rekindle Relationships leave messages at this number?

Yes

No

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

List 3 Goals/Subjects that you wish to address during your coaching sessions

Goal 2

Goal 3

Based of your perception, briefly describe the difficulties you are experiencing.

Disclaimer: The Client is aware that the coaching relationship does not represent psychological counseling or any kind of therapy. The Client is also aware that coaching results can vary and are not guaranteed. The Client agrees that he/she is entering into coaching with the understanding that the Client is responsible for his/her own decisions and results. The Client also agrees to hold the Coach free from all liability for any actions or results for adverse situations created as a direct or indirect result of advice given by the Coach. Session Contact Procedure: The Client shall contact the Coach at the agreed hour. If the Client fails to make the appointment time, the Client is still responsible for the coaching fee, unless 24-hour notice was given to reschedule the call. The Coach will make every effort to reschedule with the client. Sign your name below

Date

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