Coach Judi Stifel, Life & Relationship Coach
Personal-Self Quest & Relationship Negotiations Workshop Registration Form
After you have scheduled your appointment or reservation, please print, complete this registration form, sign, and bring with you with payment to the first meeting. Please note that this is an educational program only and I am acting as an educator and coach, and not a therapist and with no intention of practicing any kind of therapy or being liable from a therapy perspective. I am serving education and not therapy. Please practice Due Diligence as  you would with any other form of education in which you participate. Judi Stifel
Name:___________________________________________ E-mail Address: ________________________________
Address: (optional)________________________________________________________________________________
City:__________________________ State:__________ Zipcode:___________________
Phone: _____________________ Phone: _______________________________
Marital Status:________________ Age Range:_______________________
Have you brought someone with you?________  What relationship are they with you?________________________
If you have brought a minor, what is their age?  ___________________ What is their gender? ______________
What issue is your chief concern?____________________________________________________________________
What is your chief obstacle?_________________________________________________________________________
What is your main goal? ____________________________________________________________________________
What is your short-term goal?_______________________________________________________________________
What is your long-term goal?________________________________________________________________________
What other steps have you taken to reach your goals?___________________________________________________



If you have brought someone with you, what are their issues or your issues with them?
How did you learn about my workshops?______________________________________________________________
Is there something special you would like me to address for you?__________________________________________


Do you understand that you need to attend all sessions, and in the correct order presented to gain the full
benefit from the program as each session is foundational for the next? ______________________________________
Do you understand that this program is educational and does not constitute therapy for you
or your companion?________________________________________________________________________________
If you are attending with your minor child/children, do you give permission for them to attend?____________________
I am an Educator and Coach. My products and services are educational/coaching programs and materials. "Therapists" work from a
disease model. "Coaches" work from a healthy person model and we educate and support. My purpose in presenting information is 
to educate and coach as best I can with the hope that this education and coaching will enrich the lives of others and help them reach
their various goals, whatever they may be. I  have no way to guaranty the effectiveness of any program for a specific person, and I 
am in no position to control or be liable for how this education is used by the recipients, nor can I guaranty that it will be in any way 
useful. As with all education, Knowledge is Power, but not until it is used responsibly and effectively by the recipient.

Judi Stifel, Life & Relationship Coach
Appointment for In-Person or Telephone Counseling - Email:


Print Name:__________________________________


Sign Name:__________________________________ Date___________________________

Judith L. Stifel 1996–2012. All Rights are Reserved