Intake Form
for coaching With Dr. Carolina Raeburn
MM slash DD slash YYYY
(e.g., friend, referral, Google search, provider directory, etc.)
Please enter a number from 1 to 10.
Please enter a number from 1 to 10.
Is it ok to text you?(Required)
Is it ok to email you?(Required)
From time to time, I may send out greeting cards, etc. Would you be comfortable receiving mail at your home or office address? *(Required)
Disclaimer: Coaching is not therapy. Raeburn Coaching does not provide therapy, diagnosis, or any form of mental health treatment. If you live in Florida and would like to learn more about our clinical psychology practice, visit