Name (required):
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Phone Number:
Address:
City: State: Zipcode:
May I have permission to mail to this address?
yesno
Gender: MaleFemale
Date of Birth:
Others living with you at your home, and relationship to you:
Primary Physician: Phone:
Any Significant Health Problems?
Have You Used a Life Coach Before? yesno
If Yes, When and With Whom?
Give a Brief Description of Treatment:
How Were You Referred to Our Office?
What Factor(s) Attracted You to Our Coaching Service Over Others?

Nearest Relative Other than Spouse: Phone:

Disclaimer: Coaching programs and services described herein are intended to provide individuals and couples with a confidential and supportive process and structure through which they may achieve personal or relationship goals more quickly and with more ease. Coaching is not a substitute for psychological counseling. In no way is it intended to be a means of psychological or medical diagnosis or treatment, nor should it be a substitute for regular or specialized psychological/medical care. Please consult a licensed health professional in your geographic area as needed. By submitting your credit card information, you are representing that you own that credit card or have the authority to use it. Dr. Turpeau makes no guarantees or warranties that coaching clients will reach any specific goals. The coachinng service is not intended for individuals who are actively contemplating suicide or suffering from a severe mental/emotional disorder. If this describes you, please call 911, contact your nearest hospital emergency room, or call 1-800-SUICIDE (1-800-784-2433).