Pause with Purpose Collective

CONFIDENTIAL CLIENT INTAKE FORM

So we can help you in the best way possible, please answer all questions fully. If you have any questions regarding this intake form please contact Tania Davies at contact@taniadavies.com.

First Name *

Last Name *

Phone *

Email *

Country

Occupation *

Date of birth (dd/mm/yyyy) *

How did you hear about Tania Davies? *

What made you join the collective right now? *

On a scale of 1-10 (10 being highest), how overloaded do you feel most days? What is the main area or life you feel it most? *

Are you currently experiencing anything that could affect participation? (optional)

Is there anything else you would like us to note prior to your first session?

Confidentiality and expectations *

I understand this is a coaching-style group program and not a crisis service.

I agree to keep other participants’ sharing confidential.

I understand calls are recorded and replays provided.

Terms and Conditions

I HAVE READ, UNDERSTOOD AND AGREED TO THE TERMS AND CONDITIONS. *

I agree to the terms above *

Signature *

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Date *

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