This questionnaire is confidential and goes directly to the PIVOT team.
What are you signing up for? * Select here Weekly Coaching Glass House Personalized PIVOT Couples PIVOT Family Intensive
Email *
Phone *
Date of Birth *
Please summarize how we can help you. *
How did you hear about us? * Select here Therapist Friend / Family Member Internet Other
What types of therapy have you had in the past and when? What was the outcome? *
What workshops or intensives have you attended? What was the outcome? *
Please list any pertinent medical or mental health conditions. *
If you're coming to Glass House for your work, what do you take in your coffee?
We'd like to know more about your personality! What are your top two strengths? *
Are you reading any books? If so, which?
Do you consider yourself an introvert or extrovert? *
What is your favorite T.V. show?
How do you spend your "free" time? *
What do you do for fun? *
What are your general hopes for your time with us? *
Anything else you would like us to know about you?
