Consultation Form

First name:*
Last name:*
Email address:*
Phone number:*
Skype handle:*
Primary location and address for our records:*
Date of birth:*
How did you hear about Leslie?*
Have you worked with a coach, mentor, therapist or other provider before? If so, what were you receiving support with, and how was the experience for you? *
Please give us a brief sense of what has come up for you around reading When Change Takes Times: The eBook.*
What specific challenges or questions would you like to receive support with?*
Are you currently aware of how your past experiences might be contributing to your current circumstances?*
Please list any accomplishments that you’re proud of.*
Might you also interested in long-term work with Leslie? *
If yes, is fee a concern for you? Please let us know if you may need access to “sliding-scale” services and if so, share a little bit about your current financial circumstances so that we understand your needs.*
Is there anything else that you want us to know?*

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