Client Intake Form | Jan Luther, Tapping and Coaching for Healing Your Grief

My Client Intake Form is very thorough in nature and saves us time by gathering your information up front so that we can devote that time to your Personal Coaching Session.

Please take a few minutes to fill out and submit the form below in preparation for our time together. Thank you!

This form collects your name, address, phone number, email address and other personal information related to your request for a personal coaching session with Jan Luther and The Rejuvenation Station, LLC. Please click here if you would like to view our Privacy Policy and see how we protect and manage the information you submit.

I consent to having Jan Luther and The Rejuvenation Station, LLC collect my personal information via this form. *

Yes

I have reviewed and understand the policies and information contained in the General Office Information web page. *

Yes

STOP! You do not need to submit this form. Based on your response, we're probably not a right fit for coaching. Belief in God/a Divine Creator is a necessary requirement for working with me. You can close this window.

Full Name *

First names don't always make it clear if you're a man or woman, so please let me know if you're Male or Female. *

Male

Female

Address *

Address

City

State/Province

Zip/Postal

Country

Home Phone Number (XXX-XXX-XXXX format please) *

Mobile Phone Number (XXX-XXX-XXXX format please)

When were you born? MM/DD/YYYY format please. (This is needed to ensure you are over 18 years of age.) *

What communication method do you prefer to use when we get together for your personal coaching sessions? *

Zoom

Zoom (but without Video)

Please briefly describe the challenge for which you would like assistance. *

How long have you been struggling with this challenge? *

What was lacking (or didn't work) for you with that coach or therapist?

Obviously, you may be feeling doubt or concern about trying again. I would, too. On a scale of 0-10, how high is your resistance or fear for starting this work with me? (10 being very high and 0 being no hesitation at all.)

0

1

2

3

4

5

6

7

8

9

10

Don't worry if you rate this at a 10 and are feeling very resistant. Doubt, fear and anger are normal when you've been hurt and disappointed; especially if you trusted someone to help you and they didn't have the skill, the patience and/or the wisdom to do so. This may be where we'll do our best first work -- let's clear out the resentment and disappointment to make way for hope, excitement and certainty!

What else have you tried to help you with this challenge? *

What do you really, really, really want right NOW? *

What do you need first and foremost? *

If you could make a wish and the pain/problem/challenge would be replaced with the perfect circumstances and solutions, what would that look, sound and feel like for you right now? *

Do you own your own business? *

Yes

No

What is the name of your business?

How long have you been operating this business?

Please provide me with your website address. (If you don't have one, please enter "None.")

Please provide me with your Facebook fan page address. (If you don't have one, please enter "None.")

How did you hear about me? *

Who referred you?

If you selected Other above, please let me know how you heard about me.

Do you know about and/or have you ever experienced Emotional Freedom Techniques (EFT) before? *

Yes

No

What is your experience with EFT

Watched a video on EFT

Participated in an EFT teleclass

Used EFT with another coach/practitioner

Other

If you selected "Other" above, please give me a brief description of your experience with EFT and Tapping.

Don't worry if you're not familiar with EFT. I'll provide you with more information on that.

Do you know about and/or have you ever experienced The EGO Tamer® (TET) Tapping Technique before? *

Yes

No

Don't worry if you're not familiar with TET Tapping. I'll provide you with more information on that.

Please indicate that you have read the Personal Coaching Session Terms & Conditions (there's a link below) by checking the box below and providing your signature in the space provided. *

I've read and agree to the terms and conditions in the Personal Coaching Session Terms & Conditions

Signature *

Clear

Upon submitting your Client Intake Form, you'll be taken to the PayPal payment page to pay for your session. Once your payment is complete, DO NOT CLOSE YOUR BROWSER because it will open my appointment calendar where you can select an available appointment time.

Click here to review my Personal Coaching Session Terms & Conditions.