Private Coaching Application Name: * Email: * City & State * Age: * Phone: * This application information will be kept private and secure. It will be used to help me determine if private coaching is the right fit for you. After you submit this application, I will contact you directly to discuss it in more detail and answer all of your questions. Thank you! 1. What are your biggest challenges and fears with dating and finding love? * 2. What does your ideal love relationship look like? * 3. Which of the following have you tried for the purpose of improving your love life? * Magazine or online articles, etc. Self-help books Workshops and retreats Coaching Therapy or counseling Astrology, horoscopes, tarot cards, etc. OtherOther 4. How have these strategies helped you improve your love life? * 5. If these strategies have NOT helped, explain why. 6. If you have experience with professional therapy or counseling specifically for issues that have affected your relationships, please briefly explain these issues: 7. On a scale of 1 to 10, with 10 being the highest, how would you rate yourself on the following? My commitment to doing the work on my journey to finding love: * 1 2 3 4 5 6 7 8 9 10 My commitment to following a program, including completing self-exploration exercises: * 1 2 3 4 5 6 7 8 9 10 8. If you met your ideal romantic partner, your life would change in these ways: 9. Which of the following statements describe you? (check all that apply) * I am open-minded and willing to try dating a new way with the goal of finding a long-term relationship. I see value in completing self-exploration exercises. I want straightforward, easy-to-follow guidance with specific action items. I know I deserve love, even if I did not receive the love and nurturing I needed in the past. I am willing to learn and practice open and honest communication with others. I accept myself and love myself (or at least like myself a lot). I am willing to recognize positive and negative patterns and behaviors in myself and in my relationships with others. If I get stuck in an area that is beyond the scope of the Seven Steps to Love program and coaching, I am willing to seek outside professional therapy or counseling. 10. Your biggest fears and frustrations about dating and finding love include: * 11. What are you specifically wanting and expecting from private coaching : * 12. Private coaching with Jen is a significant investment. Assuming the time and money commitment work for you, are you willing to invest both as needed to achieve your goal of dating a new way? * Yes No If you are human, leave this field blank.