Name:

Email Address:

Daytime Telephone Number:

(Both email and telephone must be valid for us to contact you!)

Your Sport:

Years as an athlete:

Sport experience: --Select One-- Beginning Intermediate Advanced Elite High School College Professional

Please describe your top 3-5 goals you would like to achieve in your sport?

Describe your performance issues as they relate to your mindset. Some examples:

• "I truly believe that I freeze up in competition. Everytime I am up at bat, I think this and strike out."
• "I practice all the time and keep working to perfect my physcial skills. But, no matter how much I practice, my performance in competition doesn't seem to improve."
• "I always seem to perform better during practice than when in competition."
  

Why are you considering working with a sports psychology consultant or mental game coach?

Have you worked with a mental game coach previous to contacting Protex Sports? Yes No

What do you hope to accomplish working with a mental game coach or sports psychology consultant?

How soon would you like to work with a mental game coach? -- select one -- Immediately In 30-60 days In 60-90 days In 3-6 months In 6-9 months In 1 year Haven't considered a time Just looking right now

Do you remember how you heard about us? If so, please provide us with the name of the source or referral. (If you don't recall, simply put N/A in the space below.)