Registration Form

Please complete the following application and we shall contact you, promptly, to schedule your individual coaching session. Specifically, upon receipt of your completed form, I shall email you to:

  • Set-up a weekly Coaching Call time and day of week.
  • Arrange secure payment (no payment required with Registration)
  • Determine our First Session date.
  • Provide you a Welcome Pack with materials to get you started.

All information on the form will be treated confidentially and your information shall not be sold or traded to any other individual or organization. Therefore, please answer all the questions as truthfully and completely as possible at this time.

NOTE: If you feel you need a brief conversation, to confirm this the coaching program for you, please so indicate in the space provided on this form.


List the 3 things you want to accomplish in the next 90 to 180 days? (Must be very focused, specific, not general such as “in love”, “happy”, etc, and must include means of measuring progress / result. )

1
2
3
 
 

What are 3 important skills, resources and/or strengths that you can bring to bear to obtain your 3 wants?

1
2
3
     

Describe the barriers you anticipate, or roadblocks you “usually” experience, when trying to achieve Goals.

     
Do we need to review anything for we start; i.e. for your comfort / confidence?
No
I am ready to start now
Yes
What I need to discuss / want more information on is:
 

Must someone be consulted before you commit to the coaching process?
(If so, please obtain agreement before submitting this form.)

No
I am over 18 years of age and can make the decision myself.
Yes
And I have obtained agreement from the required party(ies).
 
 

At this point in time, thinking of the goals you wish to achieve – and certainly without any obligation – how long / which Plan Option seems to make sense to you

3 Months (3 – 4 week units), a 20% discount. RECOMMENDED

6 Months (6 – 4 week units), a 33% discount.

1 Month (1 – 4 week unit) DISCOURAGED, you probably are not really committed to change.

As we decide to move forward, together, what is your preference for Payment:

VISA
 MC
AMEX
PayPal
Other

 

Full Name, First, Last:

 

What you liked to be called:

 

E-mail::
 

Company:

 

Home Telephone:

 

Work Telephone:

 

Address: :
 

Address line2:

 

City:

 

State / Province / Other:

 

Postal / Zip:

 

Country:

 

Facsimile:

 

Would you like to subcribe to the Fortnightly Fast-Track Newsletter?

Yes, please sign me up
No, not at this time


 

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All Rights Reserved. For permission to use materials contained herein, please email Lyle@coachforoutcomes.com