Private/Group Coaching Request

The Private Coaching and/or Group Coaching that I Want is: *
---Half Hour ConsultationOne Hour Consultation9 Hours A Full Day of Empowerment Coaching!One Month Intriguing IntroductionThree Months Compounding ConfidenceSix Months Progressing ProsperityTwelve Months Tangible Transformation

About You

Full Legal Name: *

Date of Birth: *

City and State of Residence: *

Country: *

Phone: *

Preferred Contact Information

What name do you want me to call you? *

What is your preferred method of contact? *
---PhoneEmailEither

Your Email (required)

Contact Phone Number: *

Contact Phone Type *
---MobileHomeWork

Best Day(s)/Time(s) to Call:

Work Information

Occupation/Job Title: *

Company Name: *

Company Website: *

Company Address: *

Work Phone Number: (either direct line or general switchboard with extension) *

Phone Etiquette:

Degrees & Education Level

Emergency Contact

Name: *

Phone Number: *

Email Address: *

City & State of Residence: *

Relation to You: *

Appointment Information

Date(s) Requested: *

Time of Appointment: *

Location: *

How did you find my website? (Please provide as much detail as possible, such as search terms used, in which search engine, and how many pages did you scroll down before finding it.)

Specific description of the services in which you are interested: i.e. how you feel we may be able to assist you.*

Tell me a little bit more about yourself.*

Any Additional Comments or Questions: (Also, if unable to provide certain information requested, please also use this box to tell me the reason.)

What happens next?

After you hit submit, you will receive an acknowledgement from me that my system has received your submission. Next, I will contact you when your verification is complete. Please keep in mind that this could take up to a week, as I am often booked on longer engagements, and I am completely devoted to the client I am currently serving. So submit early!

In fact, if you are unsure of when you’ll be able to start but are confident you would like to do a coaching package with me in the future, you are welcome to complete my reservation form early (leaving the date[s] blank and noting the reason to me at the bottom of the form). That way you can move ahead through the screening process and be all set to rapidly secure a date when you are ready.

Once you have passed this initial screening, we will talk on the phone to see if we both feel like we are compatible and to find out if your desires meet my abilities. If we both want to proceed, then we will set up your coaching structure and schedule your first session. Before your first session, I would like for you to fill out a detailed client information form and a needs audit along with some fun “get to know you” questions. We can do this over-the-phone if you prefer. Know that many people find the writing process enjoyable, and find it helpful to have time to reflect about themselves, and even learn more about themselves in the process.

I am delighted that you want to share about yourself with me in preparing for a possible quality and lasting client-coach relationship. Life is short. Time is precious and so valuable. I consider the time you have spent studying my site and your time and effort towards this booking, a gift in and of itself.

Thank you!
Sincerely,
Dr. Stephanie Lang