Fill out my Confidential registration form and preparation questionnaire!

These forms will help me get to know you better before we start so that we can maximize our time together.

Personal Information

As a Licensed Clinical Social Worker, I am bound by state licensing regulations to uphold your confidentiality and practice in an ethical manner. This includes informing you if I think you would benefit more with a different service. In addition, any request for disclosure of your personal information requires your permission and informed consent. Since I am working on an International Coaching Federation license, I do ask if I can release your name and telephone # to verify the required coaching hours. NO other information is allowed on the form which is only viewed by a few people.

connie signiture

Preparation Questionnaire

a clearly articulated goal is a good place to start the change process. If you are not sure how to summarize your goal, the attached questionnaire may clarify your desires.  Please complete the following questionnaire prior to our first coaching session.   These questions deserve your careful consideration. It is my hope that they will help you organize your thoughts and clarify your goals. This is the beginning of an important change process for you, so I will give your answers thoughtful attention prior to our first meeting.



Thank you for your thoughtful response. I look forward to reviewing it with you. 

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