Client Application

Note: If you are unable to see all of the fields, press “TAB” and the next field will appear.

First Name:

Last Name:

Address:

City:     State:     Zip:

Telephone number:

Email address:

Date of Birth:     Ethnicity:

Number in Household: adults     children under the age of 18

What was your adjusted gross household income in the last calendar year?

Time zone you live in:

Times available for coaching sessions:



Have you worked with a coach before?

If yes, please list the person, organization, or company that you have worked with:

Would you prefer:

Tell us a little about yourself and your current situation.

What do you hope to accomplish by working with a coach at this time?

Why do you think you would be a good candidate for this coaching program?

How did you hear about us?

Please indicate that you have read the expectations listed below and agree.

W4C3 Client Expectations:

  • Female (includes transgender and nonbinary), 18 years of age or older, English speaking, live in USA or Canada.
  • Annual household income of $70,000 or less.
  • Abide by the following policy: W4C3 does not discriminate based on race, religious or spiritual beliefs, sexual orientation or political affiliations in any way. We are an inclusive community dedicated to changing the world one woman at a time.
  • View W4C3 Orientation Presentation.
  • Attend regularly scheduled coaching sessions as agreed upon with coach. Provide coach with 24 hour notice if unable to make scheduled time.
  • Regular access to phone and/or skype.
  • Pay $35 fee (by PayPal or Credit Card) for each round of 12 coaching sessions. (Directions for payment will be given upon acceptance into the program)
  • Complete a client intake survey and a debrief survey at end of 12 sessions within 2 weeks of last session.
  • Communicate with W4C3 with questions, concerns, ideas, etc.

I agree  Agree         Date:

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