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Answer these questions so we can best help you
Funnel-New Client Questionnaire
How are you feeling today?
Confirm email here
Please indicate the pronoun you would like to be referred as
Eight characters minimum One lowercase letter One uppercase letter One number One special character
Select All Conditions You've Had Issue With
Marital Status
Are you seeking help alone or are you doing this with your partner?
Please indicate if you are in a heterosexual relationship

Answer if you are married, living together, engaged or dating

Please provide partner information if in a marital relationship
Please provide partner information if in a marital relationship
Confirm email here
Have you made your spouse/partner aware they will be receiving an invitation to complete this questionnaire?
Make sure you let your spouse know they will be receiving an email invitation to complete this form.
Is your marriage/relationship in serious trouble?
Are you considering breaking up?
Are both of you committed to getting help for your marriage?
What is your spiritual orientation?
If you are a couple this is needed for your relationship assessment.

Let us know how you found us

Share what other search engine, friend or other source for this referral
What words did you use to search on?
Are you just now looking for a therapist or did you start looking a while back and just decided it was time to get help?
Have you been to our website at LifestyleTherapyCoach.com?
Are you thinking about hurting yourself or someone else?
If you are thinking of hurting yourself or someone else you should call 911 and let them know so that you can get assistance right away.
Are you looking for us to prescribe medicine for you?
We don't prescribe medicine.
We do not offer in-person sessions. Are you OK with video conferencing?
We have found that video conferencing is just as effective as face-to-face. We utilize Zoom primarily.
Are you ready to do something different?
Just making sure you are a serious client in a position to put your all into this process.
Are you prepared to spend the time needed to work on your goals?
Do you have time for this in your weekly routine and are you willing to focus on this for extended amount of time?
Are you prepared to cover the cost of these services?
One must consider what resources they have available to invest in therapy and coaching

While we do not accept insurance we have affordable options for you. We will discuss these options during your free sizzle evaluation.


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