Leanne Million B.F.A., B.Ed.

Certified Life, Relationship, and Sexuality Coach 
EMPOWERED POLY Coaching Services

Intake Form

For our Empowered Poly coaches to help you effectively, please complete this form to let us know where you are currently and to acknowledge that you understand everything.

Intake Form
Preferred Name
Preferred Name
Okay to Email this address?
Okay to Call or Text this number?
Are you currently suffering from any physical or emotional symptoms related to traumatic experience?

In order to move forward, please read and understand each of the following items and check them off:

Agree that coaching isn't psychotherapy
Agree with drugs and alcohol message
I waive liability
I take responsibility for my choices
Legal release agreement
I understand the risks
I understand the technology required
I've read the above and agree to them
I agree to all of the above