Family Coaching Intake Form

All information is strictly confidential.

Name*
First Last
City/State*
Phone*
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?*
Is your loved one using cannabis?*
- Yes
- No
- I don't know
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?
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