Consultation Form

Please tell me a little bit about you in advance of our exploratory session.

Simply fill out the form below, fill in the security form (so I know you are a human!) and press submit. Then, on the "Thank You" page, you'll choose a time slot via my online scheduler.

I look forward to getting to know you and creating a road-map to your extraordinary relationship life!

About you:

Your Name:
Your E-Mail address:
Your Age:
How did you hear about me?
Your current relationship status:
Your desired relationship status:
Any children? If yes, how many (include ages and names, if you want):
Your City and State:
Your occupation:
How much do you work?
Please list 3-5 challenges you have in the area of relationships, sex and intimacy:
Please list 3-5 goals you have in the area of relationships, sex and intimacy:
Have you been in any abusive relationships? Please explain with as much detail as you can:
Do you have any chronic health conditions, and/or anything you’d like to improve with your health?
In you general diet, please give me sense of what you eat in a typical day. Please include how much you eat refined white flour products (bread, muffins, bagels, tortillas, pasta, etc.), refined sugar products (candy, pastry, cake, pie, soft drinks, etc), artificial sweeteners (Splenda, Nutrasweet, Saccharin, etc), dairy (milk, cheese, sour cream, etc), alcohol (wine, beer, liquor, etc.) and vegetables:
Do you have any addictions? Any history of depression? Mental instability? Eating disorders? Sexual trauma and/or abuse? Please explain with as much detail as you can:
Are you on any prescription drugs? If yes, for what reason?
What is your experience, if any, with therapy, coaching, counseling and personal growth work?
What interests you most about working with me?
Are you more interested in individual coaching, or coaching along with your partner(s)? Why?
Anything you’d like to add about yourself?
Any questions you have for me?

Consultation Form

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