Contact Us

If you have any questions or need assistance, please don't hesitate to reach out. I'm here to help and would love to hear from you!

Name

First Name

Last Name

Phone

(###)

###

####

Birth Date

YYYY

Who referred you?

What motivated you to seek coaching at this time?

What specific goals or outcomes are you hoping to achieve through coaching?

Have you worked with a coach or counselor before? if so, what was your experience?

What challenges are you facing right now that you'd like support with?

Are you committed to making changes and taking the necessary steps to achieve your goals?

*Jeremy is not a licensed medical provider and is not rendering medical diagnosis or treatment. The information shared during sessions is to bring clarity, release energetic blockages, enhance well-being and to help clients uncover what is getting in the way to living a more vital and empowered life. Always consult your doctor or health care provider for a diagnosis and treatment plan.