Contact

Area of Interest*

Name*

First Last

Phone

Email*

Company Name*

Company Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Event Date of Interest*

Organization Type*

Middle School
High School
College/University
Non-Profit - Religious
Non-Profit - Non-Religious
Corporate

Projected Budget or Honorarium for Securing Services*

$100-500
$500-1000
$1000-5000
$5000+

Venue*

Name of Facility

Venue Address*

Street Address Closest Airport City State / Province / Region ZIP / Postal Code Country

Name of Event*

Purpose of Event*

Time of Event*

Topic Chosen for Presentation*

What time(s) do the session(s) begin and what is(are) the requested duration(s)?*

Estimated Number of Attendees*

Event Attendee Demographics*

Open to Public*

Will this event be open to the public?

Yes
No

Tickets*

Will tickets be sold for this event? Ticket sales must be approved by OHL.

Yes
No

Recorded/Live Stream*

Will this event be recorded or live streamed?

Yes
No

Product Sales*

Can products be sold at this event?

Yes
No

Event Contact Name*

First Last

Event Contact Phone*

Event Contact Email*

OHL does not hold dates for non-committal inquiries. OHL will TEMPORARILY hold dates once a FULLY executed agreement has been reached as evidenced by a signed contract with both signatures. Dates are NOT reserved until you have received confirmation that your deposit or full payment has been received.

Age*

What age category do you fall under?

12-18
19-30
31-50
50+

What area(s) of your life do you feel you need coaching assistance?*

What was the final straw to seek a Life Coach?*

What are your expectations of a Life Coach?*

Date*

When is the expected date you would like to start your sessions?

How often do you hope to meet with a Life Coach?*

Weekly
Biweekly
Monthly

What is your Budget for this service?*

Age*

What age category does person seeking counseling fall under? (If applying for someone underage please call 858-256-6736)

2-18
19-30
31-50
50+

How often do you hope to meet with a Counselor?*

Weekly
Biweekly
Monthly

Do you have insurance?*

Yes
No

Does your insurance cover counseling?*

Yes
No

Have you ever received counseling before?*

Yes
No

What is your Budget for this service?*

Date*

When is the expected date you would like to start your sessions?

Number of Parties Involved*

How many parties are involved in this request for mediation? (If applying for someone underage please call 858-256-6736)

1-2
3-5
6+

Situation*

Please describe the situation and why is a mediator being requested?

Message*

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Address

Email

Phone

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