Intake Form

Name*

First Last

Email*

Phone*

Skype Handle*

Primary location and address for our records*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth*

Preferred meeting time(s) (please give us a few options, if possible, and feel free to rate your preference): *

Are you interested in therapy or coaching? (Please let us know if you need more information about the difference between therapy and coaching.) *

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?*

How did you hear about Leslie?*

What is your biggest challenge currently?*

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.*

What do you do for a living?*

Is fee a concern for you? Please let us know if you may need access “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 you want us to know?*

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