contact

Request Free Coaching Consultation

Please answer each question below and click submit once. You will be contacted within 48 hours to set up your appointment.

Please rate your life in the following areas:(1-worst, 5-best) Spiritual Life, Relationships, Finances, Family, Business/Career, Personal Growth

Please select two of the areas above that you would like to work on, that would make the greatest difference in your life.

Please indicate one goal you want to attain in the next 6 months that would make a HUGE difference in your life.

What one thing do you want more of in your life right now?

List 3 things you are tolerating now in your personal life or business.

What one thing would you like to achieve, but aren't sure how to do it?

Below are some typical results experienced by my coaching clients. Which 3 are most important to you? (direction, focus, accountability, a new perspective, relationship success, strategies, better finances, motivation, new challenges, other-please list)

How well do you keep your commitments when taking advice or working with someone towards your goals? (very, moderately, not too much)

If we decide to work together, how affordable is the coaching investment? (very, moderately, not affordable)

Considering the goals you have, how long do you think it makes sense to work together to achieve them? (3 months, 6 months, 1 year, longer than 1 year)

I understand that if I am not satisfied within the first month, I may cancel my future session(s)within the first month.

YesNo

If after our initial complimentary session we decide to work together, how soon would you like to begin? (within a week, within a month, within the next 90 days)

Is anyone else's agreement required prior to beginning your coaching sessions? (example: company, business partner, spouse)

YesNo

Your name:

Business name and your title (if applicable):

Email address:

Residential phone:

Cell/mobile phone:

Work phone:

City and State

Country

Please check below to subscribe to monthly newsletter.

Additional Comments:

Your Name:
Your Email:

Contact Information:

Leelo-Dianne Bush, Phd
Certified Professional Coach
239-540-4660
Fax 239-540-3340
Click To Email Me

IMPORTANT:
If you are serious about living an abundant life and are willing to make changes in your life or business
to achieve your goals, I offer a 30-minute, complimentary exploratory session by phone. This is to see
whether we are a good fit for coaching and to make sure our partnership will make a significant impact
on your life. THE FORM BELOW IS FOR YOU.

If you are interested in only a sample coaching experience or are unable to make an investment in
coaching at this time, please do not use this form.

If you interest lies in becoming a life couch yourself, please visit www.pccca.org.

Click HERE to read our Privacy Statement.