Private consulting intake form | Jillian Aurora

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WITH EVERY PURCHASE, YOU CONTRIBUTE TO EMPOWERING ONE MORE WOMAN TO TAKE BACK HER LIFE

We invite you share your interest in working with Jillian

First Name

Last Name

Email (used to send appointment reminders)

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Country

What topics are you seeking Jillian's services for? (Please check all that apply)

Self Worth (identity reclamation, raising standards, boundaries, assertive communication)

Conflict resolution and reconciliation

Leaving a destructive relationship or group

Recovering from destructing relationships

Recovery from religion

Deconstructing patriarchal conditioning

Building an equal partnership relationship

Family estrangement and/or parental alienation

Co Parenting/Parallel Parenting

Why do you want to work with Jillian?

How did you find Jillian and what about her work resonates with you?

Please describe what's working well in your relationships.

Please describe what's NOT working well in your relationships.

What relationship patterns do you struggle with most?

What do you hope to accomplish through working with Jillian?

Will working with Jillian jeopardize your safety in any way?

Yes

No

Maybe

Do you understand Jillian is a self-worth and relationship consultant and strategist, and that the primary topics she will address are: self betrayal, codependency, and people pleasing? Do you understand working with Jillian means learning to get comfortable with setting boundaries, letting go of things misaligned with your values, grief, radical responsibility, and self loyalty?

Yes

No

Maybe

Jillian only accepts coaching clients on a case by case basis, if she feels her services can help the applicant. Do you understand you will only be offered a consultation if your needs appear to be a fit for Jillian's work?

Yes

No

Jillian's fees are $150 per hour session. Do you have the ability and desire to make this financial commitment? (If no, please consider Jillian's other budget friendly courses or support group)

Yes

No

Do you understand Jillian's services are not eligible for insurance payments but that Jillian does accept Health Savings Account payments?

Yes

No

Thanks for submitting!

Jillian Aurora

Self Worth Author and Facilitator

admin@jillianaurora.com

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© 2015 by Jillian Aurora

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