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Affirmative Couples Coaching Registration Form
REGISTRATION FORM  |  ALL INFORMATION IS STRICTLY KEPT CONFIDENTIAL
11Questions
  • 1
    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
    Partner 1
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  • 3
    Partner 2
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  • 4
    Married/Divorced/Partnered/Single/Widowed
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  • 5
    Emergency Contact: Name | Relationship | Contact Number
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  • 6
    Health Issues | Medications Taken
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  • 7
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  • 8
    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
    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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  • 10
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      • 11

        Please click one of the PayPal options to complete payment and submit the form.

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