{"id":81,"date":"2024-03-01T19:19:10","date_gmt":"2024-03-01T16:19:10","guid":{"rendered":"https:\/\/gracengrit.info\/form\/?page_id=81"},"modified":"2025-11-08T17:15:12","modified_gmt":"2025-11-08T14:15:12","slug":"main","status":"publish","type":"page","link":"https:\/\/gracengrit.info\/form\/","title":{"rendered":"Main"},"content":{"rendered":"<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework color:_wrapper #b808c9_wrapper' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_5' style='display:none'>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Grace N Grit Coaching Hub Client Registration Form<\/h2>\n                            <p class='gform_description'>Welcome! Thank you for your interest in coaching with Grace N Grit Coaching Hub with Coach Terry Samy.\r\nThis form helps us understand you, your story, and how best we can serve your healing & growth journey. Please take a few moments to answer honestly and thoughtfully all information is confidential.<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_5' class='color: #b808c9' action='\/form\/wp-json\/wp\/v2\/pages\/81' data-formid='5' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_5' class='gform_fields top_label form_sublabel_above description_above validation_below'><div id=\"field_5_8\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Personal Information<\/h3><\/div><fieldset id=\"field_5_55\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Full Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_5_55'>\n                            \n                            <span id='input_5_55_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_5_55_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                    <input type='text' name='input_55.3' id='input_5_55_3' value=''   aria-required='true'     \/>\n                                                <\/span>\n                            <span id='input_5_55_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_5_55_4' class='gform-field-label gform-field-label--type-sub '>Middle<\/label>\n                                                    <input type='text' name='input_55.4' id='input_5_55_4' value=''   aria-required='false'     \/>\n                                                <\/span>\n                            <span id='input_5_55_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_5_55_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                            <input type='text' name='input_55.6' id='input_5_55_6' value=''   aria-required='true'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_5_81\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_81'>Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_81' id='input_5_81' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_80\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_80'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_80' id='input_5_80' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_5_86\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Age Bracket<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_86'>\n\t\t\t<div class='gchoice gchoice_5_86_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_86' type='radio' value='18\u201325'  id='choice_5_86_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_86_0' id='label_5_86_0' class='gform-field-label gform-field-label--type-inline'>18\u201325<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_86_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_86' type='radio' value='26\u201335'  id='choice_5_86_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_86_1' id='label_5_86_1' class='gform-field-label gform-field-label--type-inline'>26\u201335<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_86_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_86' type='radio' value='36\u201345'  id='choice_5_86_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_86_2' id='label_5_86_2' class='gform-field-label gform-field-label--type-inline'>36\u201345<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_86_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_86' type='radio' value='46\u201360'  id='choice_5_86_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_86_3' id='label_5_86_3' class='gform-field-label gform-field-label--type-inline'>46\u201360<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_86_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_86' type='radio' value='Above 60'  id='choice_5_86_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_86_4' id='label_5_86_4' class='gform-field-label gform-field-label--type-inline'>Above 60<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_117\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Preferred Mode of Communication<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_117'><div class='gchoice gchoice_5_117_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_117.1' type='checkbox'  value='WhatsApp'  id='choice_5_117_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_117_1' id='label_5_117_1' class='gform-field-label gform-field-label--type-inline'>WhatsApp<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_117_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_117.2' type='checkbox'  value='Email'  id='choice_5_117_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_117_2' id='label_5_117_2' class='gform-field-label gform-field-label--type-inline'>Email<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_117_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_117.3' type='checkbox'  value='Phone Call'  id='choice_5_117_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_117_3' id='label_5_117_3' class='gform-field-label gform-field-label--type-inline'>Phone Call<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_87\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Gender (Optional)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_87'>\n\t\t\t<div class='gchoice gchoice_5_87_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_87' type='radio' value='Male'  id='choice_5_87_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_87_0' id='label_5_87_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_87_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_87' type='radio' value='Female'  id='choice_5_87_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_87_1' id='label_5_87_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_87_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_87' type='radio' value='I Prefer Not to Say'  id='choice_5_87_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_87_2' id='label_5_87_2' class='gform-field-label gform-field-label--type-inline'>I Prefer Not to Say<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_88\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_88'>City\/Country of Residence<\/label><div class='ginput_container ginput_container_text'><input name='input_88' id='input_5_88' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_118\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_118'>Occupation\/Profession<\/label><div class='ginput_container ginput_container_text'><input name='input_118' id='input_5_118' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_119\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_119'>Marital Status<\/label><div class='ginput_container ginput_container_select'><select name='input_119' id='input_5_119' class='large gfield_select'     aria-invalid=\"false\" ><option value='Select Choice' >Select Choice<\/option><option value='Single' >Single<\/option><option value='Dating' >Dating<\/option><option value='Married' >Married<\/option><option value='Separated' >Separated<\/option><option value='Divorced' >Divorced<\/option><option value='Widowed' >Widowed<\/option><\/select><\/div><\/div><div id=\"field_5_7\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Coaching Category<\/h3><\/div><div id=\"field_5_121\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_121'>Which coaching service are you interested in?<\/label><div class='ginput_container ginput_container_select'><select name='input_121' id='input_5_121' class='large gfield_select'     aria-invalid=\"false\" ><option value='Select One' >Select One<\/option><option value='Family Coaching' >Family Coaching<\/option><option value='Couple Coaching' >Couple Coaching<\/option><option value='Individual Coaching' >Individual Coaching<\/option><option value='Group Coaching' >Group Coaching<\/option><option value='Child &amp; Adolescent Coaching' >Child &amp; Adolescent Coaching<\/option><option value='Childhood Trauma Coaching' >Childhood Trauma Coaching<\/option><\/select><\/div><\/div><div id=\"field_5_90\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_90'>How long have you been together\/married?<\/label><div class='ginput_container ginput_container_text'><input name='input_90' id='input_5_90' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_115\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_115'>What are some of the challenges you are currently facing as a couple\/family?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_115' id='input_5_115' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_5_122\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_122'>Have you sought help before (therapy, pastoral, coaching)? If yes, what was the outcome?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_122' id='input_5_122' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_5_123\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_123'>On a scale of 1\u201310, how would you rate your current relationship connection?<\/label><div class='ginput_container ginput_container_text'><input name='input_123' id='input_5_123' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_124\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_124'>What would you like to achieve through coaching?<\/label><div class='ginput_container ginput_container_text'><input name='input_124' id='input_5_124' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_125\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_125'>What season of life are you currently in (e.g., healing, rediscovery, transition, burnout, growth)?<\/label><div class='ginput_container ginput_container_text'><input name='input_125' id='input_5_125' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_126\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_126'>What are the main areas you\u2019d like to work on? (Self-esteem, boundaries, confidence, resilience, clarity, purpose, etc.)<\/label><div class='ginput_container ginput_container_text'><input name='input_126' id='input_5_126' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_127\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_127'>What has been your biggest emotional or personal struggle recently?<\/label><div class='ginput_container ginput_container_text'><input name='input_127' id='input_5_127' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_128\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_128'>What kind of support do you feel you need right now?<\/label><div class='ginput_container ginput_container_text'><input name='input_128' id='input_5_128' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_129\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_129'>What does personal transformation look like for you?<\/label><div class='ginput_container ginput_container_text'><input name='input_129' id='input_5_129' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_134\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_134'>Which group coaching theme are you interested in?<\/label><div class='ginput_container ginput_container_select'><select name='input_134' id='input_5_134' class='large gfield_select'     aria-invalid=\"false\" ><option value='Select Choice' >Select Choice<\/option><option value='Healing &amp; Resilience' >Healing &amp; Resilience<\/option><option value='Confidenc' >Confidenc<\/option><option value='Leadership' >Leadership<\/option><option value='Parenting' >Parenting<\/option><option value='Marriage' >Marriage<\/option><\/select><\/div><\/div><div id=\"field_5_131\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_131'>What motivates you to join a group setting instead of one-on-one sessions?<\/label><div class='ginput_container ginput_container_text'><input name='input_131' id='input_5_131' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_132\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_132'>What do you hope to gain from connecting with others on a similar journey?<\/label><div class='ginput_container ginput_container_text'><input name='input_132' id='input_5_132' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_133\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_133'>How do you prefer to engage in group sessions (sharing, listening, reflection, accountability)?<\/label><div class='ginput_container ginput_container_text'><input name='input_133' id='input_5_133' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_135\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_135'>Name and age of the child\/adolescent<\/label><div class='ginput_container ginput_container_text'><input name='input_135' id='input_5_135' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_136\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_136'>Relationship to the child (Parent\/Guardian)<\/label><div class='ginput_container ginput_container_text'><input name='input_136' id='input_5_136' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_137\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_137'>What concerns or behaviors have you observed?<\/label><div class='ginput_container ginput_container_text'><input name='input_137' id='input_5_137' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_138\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_138'>Has the child\/adolescent experienced any major changes recently (e.g., school transition, loss, bullying, separation, trauma)?<\/label><div class='ginput_container ginput_container_text'><input name='input_138' id='input_5_138' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_139\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_139'>What do you hope this coaching process will help your child achieve?<\/label><div class='ginput_container ginput_container_text'><input name='input_139' id='input_5_139' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_140\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_140'>Have you identified any early experiences or memories that still affect you today?<\/label><div class='ginput_container ginput_container_text'><input name='input_140' id='input_5_140' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_141\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_141'>Have you previously engaged in therapy, counselling, or coaching for trauma or healing?<\/label><div class='ginput_container ginput_container_text'><input name='input_141' id='input_5_141' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_142\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_142'>What would emotional healing look or feel like to you?<\/label><div class='ginput_container ginput_container_text'><input name='input_142' id='input_5_142' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_143\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_143'>Are there areas of your life where you feel \u201cstuck\u201d or \u201crepeating cycles\u201d?<\/label><div class='ginput_container ginput_container_text'><input name='input_143' id='input_5_143' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_145\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Readiness &amp; Support<\/h3><\/div><div id=\"field_5_144\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_144'>On a scale of 1\u201310, how ready are you to invest in your healing or transformation journey?<\/label><div class='ginput_container ginput_container_text'><input name='input_144' id='input_5_144' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_146\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_146'>What kind of support system do you currently have (family, friends, faith community, etc.)?<\/label><div class='ginput_container ginput_container_text'><input name='input_146' id='input_5_146' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_147\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_147'>Are you open to incorporating spiritual\/faith-based approaches if relevant?<\/label><div class='ginput_container ginput_container_select'><select name='input_147' id='input_5_147' class='large gfield_select'     aria-invalid=\"false\" ><option value='Select Choice' >Select Choice<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><option value='Maybe \/ Not sure' >Maybe \/ Not sure<\/option><\/select><\/div><\/div><fieldset id=\"field_5_148\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >How did you hear about Grace N Grit Coaching Hub with Terry Samy?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_148'><div class='gchoice gchoice_5_148_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_148.1' type='checkbox'  value='Social Media'  id='choice_5_148_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_148_1' id='label_5_148_1' class='gform-field-label gform-field-label--type-inline'>Social Media<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_148_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_148.2' type='checkbox'  value='Referral'  id='choice_5_148_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_148_2' id='label_5_148_2' class='gform-field-label gform-field-label--type-inline'>Referral<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_148_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_148.3' type='checkbox'  value='Webinar\/Event'  id='choice_5_148_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_148_3' id='label_5_148_3' class='gform-field-label gform-field-label--type-inline'>Webinar\/Event<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_148_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_148.4' type='checkbox'  value='Podcast'  id='choice_5_148_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_148_4' id='label_5_148_4' class='gform-field-label gform-field-label--type-inline'>Podcast<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_148_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_148.5' type='checkbox'  value='Other'  id='choice_5_148_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_148_5' id='label_5_148_5' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_149\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_149'>(Please Specify)<\/label><div class='ginput_container ginput_container_select'><select name='input_149' id='input_5_149' class='large gfield_select'     aria-invalid=\"false\" ><option value='Select Choice' >Select Choice<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><option value='Maybe \/ Not sure' >Maybe \/ Not sure<\/option><\/select><\/div><\/div><div id=\"field_5_150\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Session Logistics<\/h3><\/div><div id=\"field_5_151\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_151'>Preferred Coaching Mode<\/label><div class='ginput_container ginput_container_select'><select name='input_151' id='input_5_151' class='large gfield_select'     aria-invalid=\"false\" ><option value='Select Choice' >Select Choice<\/option><option value='In-person' >In-person<\/option><option value='Online (Zoom\/Google Meet)' >Online (Zoom\/Google Meet)<\/option><\/select><\/div><\/div><div id=\"field_5_152\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_152'>Preferred Days\/Times for Sessions<\/label><div class='ginput_container ginput_container_select'><select name='input_152' id='input_5_152' class='large gfield_select'     aria-invalid=\"false\" ><option value='Select Choice' >Select Choice<\/option><option value='Morning' >Morning<\/option><option value='Afternoon' >Afternoon<\/option><option value='Evening' >Evening<\/option><option value='Weekend' >Weekend<\/option><\/select><\/div><\/div><div id=\"field_5_153\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_153'>Would you like to receive periodic updates, workshops, or group offers via email or WhatsApp?<\/label><div class='ginput_container ginput_container_select'><select name='input_153' id='input_5_153' class='large gfield_select'     aria-invalid=\"false\" ><option value='Select Choice' >Select Choice<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/div><div id=\"field_5_154\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Final Reflections<\/h3><\/div><div id=\"field_5_156\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_156'>What inspired you to take this step today?<\/label><div class='ginput_container ginput_container_text'><input name='input_156' id='input_5_156' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_157\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_157'>What\u2019s one thing you want to start healing or changing in your life right now?<\/label><div class='ginput_container ginput_container_text'><input name='input_157' id='input_5_157' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_158\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_158'>Is there anything else you\u2019d like Terry or the coaching team to know before your first session?<\/label><div class='ginput_container ginput_container_text'><input name='input_158' id='input_5_158' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_159\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Consent<\/h3><\/div><fieldset id=\"field_5_160\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >I understand that all information shared is confidential and used solely for coaching purposes.<\/legend><div class='ginput_container ginput_container_consent'><input name='input_160.1' id='input_5_160_1' type='checkbox' value='1'    aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_5_160_1' >I understand and agree<\/label><input type='hidden' name='input_160.2' value='I understand and agree' class='gform_hidden' \/><input type='hidden' name='input_160.3' value='4' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_5_161\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >I acknowledge that coaching is not a substitute for clinical therapy or psychiatric care.<\/legend><div class='ginput_container ginput_container_consent'><input name='input_161.1' id='input_5_161_1' type='checkbox' value='1'    aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_5_161_1' >I acknowledge and agree<\/label><input type='hidden' name='input_161.2' value='I acknowledge and agree' class='gform_hidden' \/><input type='hidden' name='input_161.3' value='4' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_5_162\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >I give consent to be contacted for scheduling and follow-up.<\/legend><div class='ginput_container ginput_container_consent'><input name='input_162.1' id='input_5_162_1' type='checkbox' value='1'    aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_5_162_1' >I give consent<\/label><input type='hidden' name='input_162.2' value='I give consent' class='gform_hidden' \/><input type='hidden' name='input_162.3' value='4' class='gform_hidden' \/><\/div><\/fieldset><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_5' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit Form'  \/> <button type='button'  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