New Client Intake Form

First Name *

Last Name *

Email *

Phone *

How did you hear about us? *

Ad/Promotion
Diamond In The Rough
Event
Email
Friends/Family
Gem Makers/Beyond Brilliant
Gem Makers Coach
Google/Internet Search
Media Outlet (podcast, tv, radio)
Social Media
Website
Other
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Select Team Member

Audra McDaniel
Camillie Rousseau
Coco Jonez
Monique Kelly
Nicole Steele
Sharon Phillips
Toni Lee Jones
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Indicate the type of coaching or services you are seeking at this time? *

Personal Development or Coaching

Professional/Career Development or Coaching

Family/Relationship Development or Coaching

Other

Who is this coaching for?

Myself

My Daughter

Me & My Daughter

Other

Please describe your current situation and/or the challenge(s) you are facing. *

What is the biggest challenge you’re facing in your mother-daughter relationship right now? *

How long have you struggled with these issues? / When did these issues start to arise?

What do you feel YOUR ROLE has been in the conflict? What are some ways you know you need to grow?

How does your current situation make you feel on a daily basis? *

What have you done/currently doing to improve your relationship? And, how is that working for you? *

What do you hope to gain or experience through coaching? *

How would you describe your support system right now (family, friends, mentors, community, church, etc.)? *

Is there anything else you would like to share at this time?

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