Family Coaching Intake Form

Please read the previous page before filling out this intake form.

All information is strictly confidential.

First Name:

Last Name:

City/State:  

Phone number:

Email address:

Confirm email:

Relationship to the person with bipolar disorder (i.e., partner, parent, friend, etc.):

Name of loved one:

Age of loved one:

When was your loved one diagnosed with bipolar disorder?

Briefly describe your situation with your loved one:

How did you hear about Julie?

What search terms did you use to find Julie's coaching?