NewClient form — HER Refinery Co.

H.E.R. Refinery Co. — Client Intake Form

About You

Your Journey

Goals

Logistics

Personal Information

First Name *

Last Name *

Email Address *

Phone Number

City & State

Age Range

How did you hear about H.E.R. Refinery Co.?

Faith & Lifestyle

How would you describe your faith background?

Current life season

"Before we can become, we must be willing to be honest about where we are."

Where You Are Right Now

What is bringing you to H.E.R. Refinery right now? *

What are you currently struggling with most? *

Mindset / negative thinking

Emotional overwhelm

Identity / self-worth

Fear & self-doubt

Lack of clarity / purpose

Spiritual disconnection

Relationships / boundaries

Burnout / exhaustion

How long have you been feeling this way?

Have you worked with a coach or therapist before?

Yes, coaching

Yes, therapy

Both

No — first time

On a scale of 1–10, how ready are you to do the inner work?

Not ready at all100% ready

"Becoming is not a destination — it's a direction. Let's get clear on yours."

Your Transformation Goals

What do you most want to experience or change? *

Which areas of life are you focusing on?

Mindset & thoughts

Emotional health

Faith & spiritual life

Identity & confidence

Relationships

Career & purpose

Habits & daily life

Overall wellness

What has stopped you from making this change before?

What does success look like for you 6 months from now?

Is there anything you are NOT willing to work on or discuss?

Program & Scheduling

Which service are you enrolling in? *

Preferred session format

Virtual (Zoom)

In-Person

Best days for sessions

Mon

Tue

Wed

Thu

Fri

Sat

Sun

Best time of day

Morning (8am–12pm)

Afternoon (12–5pm)

Evening (5–8pm)

Flexible

Emergency Contact

Emergency Contact Name

Relationship

Emergency Contact Phone

Final Reflections

Is there anything else you'd like us to know before we begin?

A note from H.E.R. Refinery:
Everything you share in this form is held in complete confidence. This is a safe, judgment-free space. We are honored to walk alongside you in this season and believe deeply in the woman you are becoming.

◈

Welcome to Your Becoming

Your intake has been received.

We are so honored you chose H.E.R. Refinery Co. for this season of your life.
Someone from our team will reach out within 2 business days
to confirm your enrollment and next steps.

"She is clothed with strength and dignity, and she laughs without fear of the future." — Proverbs 31:25

Renew. Align. Become.