Request A Free Evaluation for E-Coaching or Phone Coaching Sessions

Secure Questionnaire

Please provide complete information on the questionnaire below. By submitting this form you our requesting that we contact you to determine if e-coaching/counseling or phone coaching/counseling is right for you. This evaluation is free. You are under no obligation to purchase a coaching or counseling session. We will do our best to contact you within 24 hours of your evaluation request... often much sooner.

View our rates for online and phone coaching services.

Have a general question? Please use our contact us form instead of this questionnaire.


   A secret word is required to ensure privacy. We will ask you your secret word for all online communication.
   Choose a word that is easy to remember, but something only you would likely know... such as a pet’s name,
   mother’s maiden name, street you lived on as a child, etc. Note: Your secret word is CaSe-sEnsitiVe.

I agree that I am 18 years of age or older, and have read, understand and agree to the Confidentiality Limits written in website under the Privacy Section.

   If you are under 18, do not submit this form. Please have parent contact us by phone with their permission for your online
   or phone coaching/counseling session.


   IMPORTANT: You will receive our reply from Please enter our email address into your
   friends/safe sender list so the message is not rejected by your spam filter. To view our email response you will need to
   enter your secret word.

   If you are requesting a free evaluation for e-coaching/counseling, HHC will exchange up to three email responses with you.
   In the final email we will include a link to our secure online shopping cart. You can then purchase a session or session(s)
   based on our recommendation if you wish. If you choose to purchase online coaching/counseling sessions, complete
   details will be sent via email including the simple steps needed for communicating online: either using our secure
   email system, or using our secure instant messaging (online chat) system.

   If you are requesting a free phone coaching/counseling evaluation, be sure to indicate several dates/times that you
   are able to receive a call, and your phone number. Our free phone evaluation lasts for a maximum of 15 minutes. At the
   conclusion of our conversation you can decide if you wish to purchase one or more sessions. You can place your order
   with us over the phone using your credit card.

   Required! Please answer each of the following to assist us with your free evaluation.

   If you are requesting a phone evaluation: Indicate below several dates/times that are best for us to
   call you. We are in the Eastern time zone, USA.


When you click the "Send Secure Questionnaire" button above, all information you provide on our form is encrypted (essentially sent as undecipherable ‘gibberish’ that can only be decrypted and read when it arrives at our In Box).

Your information is handled in confidence. Our secure email system, CryptoHeaven, complies with HIPAA patient confidentiality protocols.

160 Lighthouse Road
Isle La Motte, Vermont, USA 05463