"*" indicates required fields Client InformationPlease list your full name:* First Last Email:* Phone:*Have you started seeing a different coach/therapist since your last intensive?* Yes No Has anything changed substantially since you last filled out the client information questionnaire?* Yes No Update Client InformationPlease explain your goals for this work as you know them now. Coach/Therapist Agreement for Post-Intensive IntegrationI understand that before my intensive can take place, I will need to have a coach/therapist that is available to do any integration work if wanted/needed. * I agree to the above. The Coach/Therapist Agreement for Post-Intensive Integration will be emailed to you after the sign up process has been completed. PaymentI understand that time-limited intensives with Dr. Julie Lopez are billed at the rates listed below. Choose the intensive package you are most interested in:* 2-day Intensive (10 hours over two days) – $9250 1-day Intensive (5 hours over one day) – $4750 1/2 day Intensive (one 2.5 hour session) – $2500 All packages include pre-intensive consultation session, post-intensive debrief session and collaboration with post-intensive integration professional.Coupon I understand this intensive package includes a pre-intensive as well as a post-intensive debrief. Furthermore, the primary coach/therapist identified through the completed agreement maybe consulted pre or post intensive as needed for integration supportTotal Payment*
