I can’t wait to help you crush your personal & professional goals!

Before our first meeting, help me learn more about your current challenges and goals for growth.

Name *

Name

First Name

Last Name

Email Address *

Phone *

Phone

(###)

###

####

How did you hear about me?

Where would you like your appointments to take place? *

Online, using your confidential portal

At my office (additional fees apply for travel cost)

In a green space, like a local park, where we can walk & talk (additional fees apply)

At a nearby coffee shop or restaurant (additional fees apply)

When are you available to meet?

Monday-Friday, 9am-noon

Monday-Friday Noon-3pm

Monday-Friday 3pm-5pm

Monday-Friday after 5pm (note: after-hours charges apply for coaching taking place after 5pm)

Tell me a little bit about what's going on:

I am interested in *

Learning to prioritize more effectively

Getting better at trusting my gut instinct

Feeling less guilty

Getting better at saying "no" and setting boundaries

Improving my general overall quality of life

Being more successful at work

Being a better partner/spouse/parent/family member/friend

On a scale of 1-10, how satisfying would you rate your overall quality of life at this time (0 being the worst, 10 being the best)? Tell me why you chose this number.

What do you think would make your life feel more satisfying and closer to a "10"?

What barriers are keeping you from living a more satisying, fulfilling, and balanced life?

Not having enough time in the day

Juggling too many priorities

Feeling unsupported at work

Feeling unsupported at home

Not having enough energy to do everything I would like/Feeling run-down

Worrying too much

Procrastinating/Avoiding things I know I shouldn't

Not trusting myself/being too hard on myself

Neglecting my self-care

Tell me a little bit more about how these barriers show up in your life.

Anything else you would like me to know?

If you aren't already, would you like to receive resources by e-mail for recognizing and preventing Burnout?

Yes!

I can’t wait to help you crush your personal & professional goals!

Before our first meeting, help me learn more about your current challenges and goals for growth.

OMpowerment Psychotherapy
Nikolai Diana Blinow, MA, CAGS, LMHC
Professional C0ach & Licensed Mental Health Counselor

897 Reservoir Avenue
Cranston, RI 02910

nikolai@ompowermentpsych.com
401-379-9998

OMpowerment Psychotherapy

Contact

HOuRs:

Monday, 2pm - 6pm
Tuesday, 12pm - 6pm
Wednesday, 9am - 5pm
Thursday, 9am - 5pm
Friday, 9am-4pm
Saturday, Closed
Sunday, Closed

401-379-9998

I can’t wait to help you crush your personal & professional goals!

Before our first meeting, help me learn more about your current challenges and goals for growth.

OMpowerment PsychotherapyNikolai Diana Blinow, MA, CAGS, LMHCProfessional C0ach & Licensed Mental Health Counselor

897 Reservoir AvenueCranston, RI 02910

nikolai@ompowermentpsych.com401-379-9998

Contact

HOuRs:

Monday, 2pm - 6pmTuesday, 12pm - 6pmWednesday, 9am - 5pmThursday, 9am - 5pmFriday, 9am-4pmSaturday, ClosedSunday, Closed

401-379-9998

OMpowerment Psychotherapy
Nikolai Diana Blinow, MA, CAGS, LMHC
Professional C0ach & Licensed Mental Health Counselor

897 Reservoir Avenue
Cranston, RI 02910

nikolai@ompowermentpsych.com
401-379-9998

Monday, 2pm - 6pm
Tuesday, 12pm - 6pm
Wednesday, 9am - 5pm
Thursday, 9am - 5pm
Friday, 9am-4pm
Saturday, Closed
Sunday, Closed