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Affirmative Couples Coaching Registration Form
REGISTRATION FORM | ALL INFORMATION IS STRICTLY KEPT CONFIDENTIAL
11
Questions
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1
Care to share what is the main reason for booking this package?
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If any, please give a brief background of your current concern, how long has it been going on and what have been done about it?
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2
May we have your contact details please?
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Partner 1
What would be the preferred name that we can address you with?
Kindly enter your full name please.
Please enter your email address here.
Please enter your contact number so we can contact you.
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3
May we have your contact details please?
*
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Partner 2
What would be the preferred name that we can address you with?
Kindly enter your full name please.
Please enter your email address here.
Please enter your contact number so we can contact you.
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4
May we know what is the marital status for each of you?
*
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Married/Divorced/Partnered/Single/Widowed
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5
Whom should we contact in case of emergencies?
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Emergency Contact: Name | Relationship | Contact Number
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6
Please disclose any pre-existing medical conditions that either of you may have.
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Health Issues | Medications Taken
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7
From the list below, please indicate the areas that concern any of you.
*
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Achieving Goals
Addictions
Anxiety
Career
Childhood Problems
Concentration
Confidence
Compulsive Behaviour
Depression
Drinking
Drugs
Exam Stress
Eating Disorders
Fears
Fertility
Food Issues
Gambling
Motivation
Memory
Pain Control
Panic
Phobias
Public Speaking
Medical Issues
Self-Esteem
Sexual Problems
Sleep Problems
Skin Complaints
Smoking
Stress
Relationships
Weight Issues
Other
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8
What is the ideal outcome you would like to get out of this session?
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Be as specific as possible. How would you assess if the session has been impactful for you? What would be the before and after difference that you are striving for?
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9
Declaration
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By signing the intake form, we have read and agree to the terms of service. The information we have given here is to the best of our knowledge, full and correct. We undertake this therapeutic coaching on the understanding that it is a collaborative process, and that progress depends in part on our own motivation and participation. We also accept that all appointments not cancelled within 48 hours will be charged in full.
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Signature and Date
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10
Would you like to confirm your session?
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ORDER SUMMARY
Total cost
SGD
Affirmative Couples Resilience Package
$
550.00
SGD
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Affirmative Couples Retreat Package
$
2,400.00
SGD
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11
Pay with PayPal
Debit Or Credit Card
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