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Request for Neuro-Linguistic Learning Coach Consultation

Please complete this confidential profile and submit it us as soon as possible. It is important that we receive your completed form at least 24 hours prior to your scheduled consultation.

Please submit your completed form by hitting the "Send Information Now" button at the bottom of the form. In order to protect your privacy, DO NOT EMAIL THIS FORM. Submit your information by hitting the "Send Information Now" button once. You can also fax your form directly to: 800-497-6614. Either way, we recommend that you print out a copy of your completed form for your records.

Client Name  
Name of Parent(s)  
or Guardian(s) (req'd  
if Client is under 18)  

Primary Email Address  
Home phone  
Cell phone  
Work phone  
Address 1  
Address 2  
Client Age  
Client Date of Birth  
Please provide a brief description of the current struggle(s) that the Client is experiencing.

Please select (check) all that apply to the client's current struggles:
Difficulty with Reading Difficulty with Math
Slow Reader Has trouble self-starting
Dislikes Reading Difficulty completing homework
Poor Reading Comprehension Fails to hand in assignments
Poor Spelling Difficulty finishing projects
Poor handwriting Test anxiety or nervousness
Difficulty with writing/composition Dislikes school
Difficulty memorizing vocabulary Suspect Dyslexia
Difficulty memorizing multiplication table Suspect ADD or ADHD

Please select (check) all that apply:
Excellent Reader (above Grade level) Enjoys skateboarding, snowboarding, skiing, BMX'ing or similar activities
Excellent at Math (above grade level) Enjoys video or computer games
Enjoys Reading Good at remembering where things are
Enjoys Math Good at puzzles
Enjoys Science Above average intelligence
Enjoys History or Social Studies Enjoys learning
Enjoys physical activity Very social
Enjoys Art Good at multi-tasking
Enjoys music Other

Please describe any other talents or abilities demonstrated by the client:
Please describe any other interests, activities or areas of study that the client enjoys:

Please select (check) all that apply to the client's current struggles:
Delayed speech or language skills Fear of school or work
Avoids eye contact Fear of social situations or groups
Difficulty following instructions Fear of heights or bridges
Generally or often inattentive Fear of the Dark
Sensative to clothing or touch Other Fears or Phobias
Over reacts to changes in routine or schedule Frequent bedwetting
Sensative to criticism Frequent nightmares or night terrors
Difficulty sleeping Alergies
Poor Diet, over or under weight Frequent headaches or migraines
Low self-esteem Obsessive or Compulsive behaviors

Please describe any behavior or emotional issues that you feel might be relevant:
In your own words, please describe any significant emotional events during the most recent 3 years:
Is the client currently under the care of a physician, psychotherapist, pathologist or licensed medical practitioner?
If yes, please explain the condition(s) for which the client is being treated and the nature of the treatment(s), including any medications.
Please include any additional information which you believe may be relevant to the current struggle(s):

Please describe as clearly as possible the results that you (the client) would like to achieve.

How did you hear about us?

Thank you for completing your information profile. Please take a moment to review your answers and add any information that you feel is relevant to achieving your desired results.


About Michael Stevenson MNLP, MTT, MHt

Michael is a best-selling author, business coach, success coach, and international speaker with impressive credentials and experience. He has helped more than 100,000 people around the world learn to use the power of the mind to turn off the "autopilot," take hold of the controls and create the life their dreams.

You can read more about Michael on his bio page.

Co-Star of the Documentary Movie
  • The Evolution of Success movie with Jack Canfield, Joe Vitale, Bob Doyle, and Others

Author of the Books
  • Influence to Profit: Turning Words Into Wealth With Ethical Influence and Persuasion
  • UnStuck: The Owner's Manual for Success
  • The Power to Create Your Day... Now!
  • Quick Fix: NLP Recipes for Bliss
  • Best-Selling Book Learn Hypnosis... Now!
  • Certified Business Coach and Business Consultant
  • Certified Master Success Coach and Certified Trainer of Success Coaching
  • Certified Master Life Coach and Certified Trainer of Life Coaching
  • Certified Funnel Optimization Expert and Customer Value Optimization Expert
  • Certified Master Trainer of Neuro-Linguistic Programming
  • Certified Master Practitioner of Neuro-Linguistic Programming (NLP)
  • Certified Master Trainer of TIME Techniques
  • Certified Master Practitioner of TIME Techniques
  • Certified Neuro-Linguistic Master Learning Specialist
  • Certified Neuro-Linguistic Learning Specialist Trainer
  • Certified Advanced Parts Therapy Specialist
  • Voted One of the Top 20 NLP "Gurus" in the World (2019 Global Gurus Awards)
Board Certificatied Through
  • International Board of Coaches and Practitioners
  • International Association of Counselors and Therapists
  • International Medical and Dental Hypnotherapy Association
  • American Board of Neuro-Linguistic Learning
  • International Hypnosis Federation
  • National Guild of Hypnotists
  • International Alliance of Professional Hypnotists
  • The Transform Destiny Company is also certified as an approved training institute by IBCP, IHF, ABNLL, and NLC.
Contact us today to schedule your personal breakthrough session, or to sign up for one of our upcoming live seminars. Call 800-497-6614 toll-free, or 714-408-4281 direct.