PIVOT Process Application

Name*

Email*

Mobile Phone #*

Age*

What is your occupation?*

What is your gross annual income?*

Less than $50,000

$50,001 - $100,000

$100,001 - $150,000

$150,001 - $250,000

More than $250,000

What best describes your current situation with relationships?*

I am in a committed relationship, where we are struggling to communicate and are hanging on by a thread

I am in a pretty good relationship, we just need more tools to communicate

I am fresh out of a relationship and really having a hard time understanding what went wrong or where I can improve

I am in a solid relationship, and am looking to grow more personally

I am single and having a hard time dating because I need to learn more about myself

I am single and want to learn more about myself and my relationships

I am a professional looking to gain more education and do more training

None of the above

What other work have you done with therapy, coaching, recovery, intensives, retreats, workshops, etc? What did you find helpful?*

Which of these statements would you like help with?*

I would like to better understand myself

Better understand the relationship dynamics in my life

Work with a coach to hold me accountable

Get out of some of the pain I’m currently experiencing

Manage the anxiety that I feel

Give us a brief description of what is going on in your life that had you book the call with us? How are you feeling about it all?*

What PIVOT service(s) are you interested in?*

Glass House Retreat

Personalized PIVOT

Weekly Coaching

I am not sure yet

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Phone

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Thank you for reaching out to PIVOT!