Think. Feel. Change! Coaching

First Name

Last Name

Best Email Address *

Best Phone Number *

Have you had an intitial consultation?

What is the problem you are seeking to change?

Please state a short summary of your diagnoses:

What have you tried in the past?

(Medical, modalities, psychiatric, pharmaceutical, etc)

What worked? What didn't?

What actions are you currently taking to change?

Why do you want to be personally coached by me?

Please choose one:

Notes/Custom Requests:

Please explain any special time or package customization requests here.

I understand that Jean does NOT do phone sessions

Please type your initials

Were you personally referred? *

If YES, please include a name.

I am interested in the following package:

The only discounts honored are those published on my website: thinkfeelchange.com/book I reserve the right to change, adjust or otherwise maintain control over packages and prices at any time and/or for any reason. Prices listed are in US Dollar.

Time Zone

Best Time Slot Availability

All time slots listed in US Central Time. Type or mark your preferred or greatest availability appointment time using the time slots listed below.