Request A Free Evaluation for E-Coaching or Phone Coaching Sessions

First Name:

Last Name:

Address 1:

Address 2:

City / Town:

State / Prov.:

Country:

Zip Code:

Gender: Select... Male Female

Email:

Phone:

   A secret word is required to ensure privacy. We will ask you your secret word for all online communication.
   Choose a word that is easy to remember, but something only you would likely know... such as a pet’s name,
   mother’s maiden name, street you lived on as a child, etc. Note: Your secret word is CaSe-sEnsitiVe.

Secret Word:

Re-type Secret Word:

Confidentiality: I agree that I am 18 years of age or older, and have read, understand and agree to the Confidentiality Limits written in website under the Privacy Section.

   If you are under 18, do not submit this form. Please have parent contact us by phone with their permission for your online
   or phone coaching/counseling session.

   IMPORTANT: You will receive our reply from healthcoach@CryptoHeaven.com. Please enter our email address into your
   friends/safe sender list so the message is not rejected by your spam filter. To view our email response you will need to
   enter your secret word.

   If you are requesting a free evaluation for e-coaching/counseling, HHC will exchange up to three email responses with you.
   In the final email we will include a link to our secure online shopping cart. You can then purchase a session or session(s)
   based on our recommendation if you wish. If you choose to purchase online coaching/counseling sessions, complete
   details will be sent via email including the simple steps needed for communicating online: either using our secure
   email system, or using our secure instant messaging (online chat) system.

   If you are requesting a free phone coaching/counseling evaluation, be sure to indicate several dates/times that you
   are able to receive a call, and your phone number. Our free phone evaluation lasts for a maximum of 15 minutes. At the
   conclusion of our conversation you can decide if you wish to purchase one or more sessions. You can place your order
   with us over the phone using your credit card.

   Required! Please answer each of the following to assist us with your free evaluation.

Preference: Choose method for communicating... Coaching/counseling via secure IM (online chat) Coaching/counseling via secure email only Coaching/counseling via telephone

   If you are requesting a phone evaluation: Indicate below several dates/times that are best for us to
   call you. We are in the Eastern time zone, USA.

Best Time:

Service: Choose coaching service... Stress Management Relationship Counseling Empowerment Achieving Goals Spiritual Mentoring Prosperity Coaching Addictions Recovery Weight Management Pre-Surgery Preparation Other

Primary Need or Focus:

Primary Goal: