Pre-Coaching Registration

Pre-Coaching Registration
How did you hear about Go2Peer (G2P) Life Coach?

Online SearchWebsiteDSHSA G2P ClientOther Source
If you selected "A G2P Client", Please list the code on the back of your referral card ending in 'REF'.
Client Contact Information
Name*

First NameLast Name
Preferred Pronoun

He, MaleShe, FemaleThey, Neutral
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
Life Coaching is offered in several different formats. Here at Go2Peer, we offer Phone or Tele-Office through doxy.me. Please select your preferred service format.*

PhoneDoxy.me
Emergency Contact Information
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
Tell Us a Little More About Yourself
Relationship Status*

SingleCommittedMarriedDivorcedOther
Your Partner's Name & Age
Children*

YesNo
Children's Names & Ages
Are you currently Employed?*

YesNoSelf-Employed
What do you do for a living?*
What do you do for enjoyment? List your top 3-5, please.*
Please list any spiritual, interpersonal, or cultural identifiers so that your Go2Peer Life Coach can be sure to respect those as you begin your journey together.*
What is prompting you to embrace this Life Coach request with Go2Peer Life Coach?*
What would like to be the outcome of your coaching journey?*
Are there any foreseeable barriers that might impact this journey?*
Go2Peer Life Coach Fee for Service Policy
The initial thirty minute meeting will be FREE. All meetings moving forward will be $60.00 per ‘therapy hour (THR, 50 minutes)' and must be paid in advance.

Al a Carte Services (Flat Rate)
- .25 THR $15.00
- .5 THR $30.00
- 1 THR $60.00
Packages Paid Weekly (10% Discount)
- 1 THR $54.00
- 1.25 THR $67.50
- 1.5 THR $81.00
- 2 THR $108.00
Packages Paid Monthly (20% Discount)
- 4 THR $192.00
- 5 THR $240.00
- 6 THR $288.00
- 8 THR $384.00
- 10 THR $480.00
I've read and understand the Go2Peer Life Coach Fee for Service Policy.*

Yes, I understandNo, I decline
By submitting this form of registration, I've offered information and details to the best of my knowledge and am willfully seeking Life Coaching services from Go2Peer Life Coach.
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