Coaching Intake - Blue Chip Minds

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Blue Chip Minds (BCM) Coaching Registration & Intake Details

We respect your Privacy

We respect your privacy and do not tolerate spam and will never sell, rent, lease or give away your information (name, address, email, etc.) to any third party. Nor will we send you unsolicited email.

Please complete the following steps prior to your first session/consultation:

Read the BCM Code of Conduct form
Read the BCM Coaching Agreement
Complete the registration form below and submit.
Select your coaching package and make your payment.

Client Details

I confirm the following *

I have read the BCM's 'Code of Conduct' I have read, understand and agree with the BCM's 'Coaching Agreement'

Select 1 option

* Indicates required field

Name *

First

Last

Employer *

Phone Number *

Date of Birth *

Occupation & Position Title *

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

What are the positive changes you are wanting to make in your life that your coach can assist you with? *

The one thing that would have the biggest positive impact on my life when it improves would be... *

If I could create my life EXACTLY as I wanted, this is how it would be... (Don't hold back! Include all areas of your life such as, career, business, relationships, health, personal development, leisure, family, finances etc) *

My realtionships with friends, family and co workers are generally... *

My movement practices are.. *

My Sleep patterns are mostly... *

I eat a healthy balanced diet (incl fresh water and vegetables) *

I would classify my current wieght as... *

My regular Spiritual practices include (Choose all that apply) *

Regular Gratitude Mindfulness / Meditation Journaling Acts of service (Community work) Time in Nature Times for Playfulness Reflecting on my goals/dreams/desires/purpose Time alone Forgiveness None of the above

What do you do to recharge? *

The Following statements apply to me (select all that apply) *

I am currently working with a therapsit I am curently taking medications I use or have used substances I am currently restricted physically in some way (Injury, recent operation etc) I have experienced mental illness in the past none of the above

Please add any additional information / comments that will help your Coach serve you better. *

I understand that personal mastery is a process, and I may experience lulls, dips and frustration as I create new and lasting habits. I agree to do my best and reach out to my coach for support and encouragement when I feel I am not progressing as I had anticipated. *

I agree to take full responsibility for my results

I require a Tax Receipt once I have made payment *

Yes

Submit details

After submitting your details, select your preferred package below and proceed to payment.

Silver Level Coaching & Accountability

A$2,600.00

Gold Level Coaching & Accountability

A$3,700.00

Blue Level Coaching & Accountability

A$5,600.00

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Home
Future Ready Leadership
The Team
What We Do
Future Ready
Ellis In Wunderland Podcast
YOU{R}EVOLUTION
Meditations
Operation Gratis
Media
Contact