Client Intake Form

If this is your first time working with Jan (or it’s been over two years since your last session), please take a couple of minutes to fill out our client intake form below. Thank you!

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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 Right Fit session.

Please take a few minutes to fill out and submit the form below.

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

Do you believe in God? *

Yes

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

As a Christian, we believe in the Holy Trinity. God, the Father, Jesus Christ and Holy Spirit. When you pray, what name do you use to address the Father? *

Heavenly Father

Father

Papa

Daddy

Abba

Other

If you selected Other above, please provide the name you use for the Divine Creator.

Full Name *

First Name (name by which you would like to be called) *

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

Email Address *

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

Phone

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

How long have you been struggling with this challenge? *

Have you worked with another coach or therapist? *

Yes

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

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

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

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

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 a "thank you" page that has the button for scheduling your Right Fit session with Jan.

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

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