THE REDISCOVERY ROOM

New Client Intake Form

Accountability Partner Services

Welcome. The fact that you are here means you have already made a decision most people never make. To stop going it alone.

Before our first session, I need to know where you are, what you are working toward, and what has been standing in your way. This form is confidential. Take your time and be honest. The more you give here, the more focused and effective our work together will be.

This is your first act of accountability. Make it count.

First Name

Phone Number

Which package interests you

How did you hear about The Rediscovery Room?

Have you read any of The Rediscovery Room guides?

What motivated you to seek accountability support at this time?

Describe what is currently happening in your life that makes you feel stuck.

How long have you been experiencing this challenge?

Less than 6 months

6 months to 1 year

1 to 3 years

More than 3 years

What have you already tried to change this situation?

What specific goals would you like to accomplish in the next 3 to 6 months?

What does success from working together look like for you?

What obstacles tend to prevent you from following through on your goals?

Which focus area is most relevant to your situation?

On a scale of 1 to 10, how ready are you to make meaningful changes right now?

What type of accountability support do you believe will help you most?

How do you prefer to be held accountable?

Direct and straightforward

Gentle and encouraging

A mix of both

What tends to derail your progress most?

How do you typically respond when you do not follow through on something?

What is your availability for a first call? (days and times)

What does showing up fully for yourself look like during our sessions?

Is there anything else you want me to know before we begin?

Here is what happens next. Submit your intake. I review it personally. Then I contact you to schedule your first session. You bring the honesty. I bring the structure and the follow-through.

New Client Intake Form

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