Client Intake – Sizzling Hot Marriage

Hello and Welcome to Lifestyle Therapy & Coaching!

Take a few minutes to help me understand how I can help you. This form is a part of my intake process. It is designed to tell me more about you so I can assess how to best help you. This form is also a tool to help you clarify your goals.

My practice is primarily focused on helping heterosexual couples achieve the marriage of their dreams. Who doesn't want a Sizzling Hot Marriage? If you are in a marital relationship your partner's contact information will be needed so they can also receive the assessment login.

After you complete this form you will be able to make your appointment for your initial session. During this session you'll get to share your goals and I'll share my recommendations for you.

I'm looking forward to meeting with you!

~Joe

Name

First

Last

Confirm Email

Confirm email here

Mobile Phone

What is the best time you can be reached by phone?

City

State

Country

What are you seeking help with? What's the problem you are facing?

Has something happened to help you make your decision to get counseling now? Please share.

Marital Status

Not in a relationship

Married

Dating/Engaged

Living Together

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

Partner Name

Please provide partner information if in a marital relationship

Partner Email

Please provide partner information if in a marital relationship

Confirm Partner Email

Confirm email here

Marriage Anniversary Date

Is your marriage/relationship in serious trouble?

Yes

Are you considering breaking up?

What is your spiritual orientation?

If you are a couple this is needed for your relationship assessment.

Let us know how you found us

How did you hear about us?

Why did you pick us?

Where did you get our number to make this call?

Other source

Share what other search engine, friend or other source for this referral

What was your search term?

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?

Just started looking

Started looking a while back

How long ago did you first start looking?

Have you been to our website at LifestyleTherapyCoach.com?

Yes

Are you thinking about hurting yourself or someone else?

Yes

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?

Yes

We don't prescribe medicine.

We do not offer in-person sessions. Are you OK with video conferencing?

Yes

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?

Very Ready

Mostly Ready

Not Ready

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?

Very Prepared

Mostly Prepared

Not Prepared

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?

Very Prepared

Mostly Prepared

Not Prepared

One must consider what resources they have available to invest in therapy and coaching

Who do you watch or listen to about relationships? Which platforms do you listen to them?

Once you submit this form you will be redirected to my scheduling link. You will also receive an email with that link.