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Intake Form

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MyPDXLifecoach, Inc. New Client Intake Form

First name*

Last name*

Phone*

Email*

Address*

Have You done this type of work before?*

If Yes to Above, Please describe what type of work, your focus and your experience.

Give us a general idea of what your goals are and if you had any experience doing this type of work before.*

How were you referred to us?

Billing Information. This information will be secure and never shared. Sessions are billed the morning of each Session.

Name on Credit Card*

Credit Card #*

Expiration Date*

Sec Code*

Zip Code Associated with Card*

All sessions will be charged on the morning of your scheduled session, so we spend no time doing this at the end of each session.

mypdxlifecoach@icloud.com

© 2026 MyPDXLifeCoach, Inc. All rights reserved.

10151 SW Barbur Blvd. Suite D-205

Portland, OR 97219

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