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Holistic Life Coaching - Contract Application

Holistic Life Coaching for Body, Mind, Heart and Spirit

To initiate a coaching partnership please fill out the form below then complete the Credit card information.

To pay by certified check or money order, E-mail me for further directives. If you're ready to invest in you
fill in this contract form today! I'll rush your introductory package and contact you immediately to set
up a schedule that suits your needs. I aim to please!

Healing Intent Coaching Service Application Form


What is your full name?



What is your street address?



What city do you live in?



What country do you live in?



What is your zip or postal code?



What is your phone number?



What is your email address?



Which is your occupation?



How old are you? (must be 18 or over)



Which is your marital status?



Do you wish to have Email or Chat coaching?



Type of Coaching Service Preferred:(check off your choice)

E-mail Coaching:

$150 US per month 		Chat Coaching:

Monthly: $50 US
Biweekly: $90 US
Weekly: $160 US
Twice Weekly: $280 US




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