Executive Assistant Concierge Intake SaskBurnout Concierge Intake (EA Only)Δ Notify Request DetailsAuthorizationGoal SettingPaymentConcierge Intake (Executive Assistants Only)Reserve a private 30-minute concierge call for your executive. A non-refundable $250 booking fee reserves a call within 5 business days. On the call, we’ll clarify fit, urgency, and the fastest path into the STG burnout program. Please complete this form as the executive assistant. If you are not an EA, use the standard booking page instead. Executive Assistant confirmationI confirm I am the Executive Assistant coordinating scheduling on behalf of the client.If you are not an Executive Assistant, please use the standard booking page.First NameLast NameYour Email (EA)Your Phone (EA)Company / OrganizationExecutive NameExecutive TitleExecutive Email Executive Phone (optional)Industry- Select -Professional servicesTechnologyHealthcareFinanceManufacturingNon-profitGovernmentOtherPreviousAuthorizationAuthorization (Required)We require client authorization to coordinate scheduling through an Executive Assistant.This authorization is for scheduling and administrative coordination only. Clinical content is not shared with the Executive Assistant.Client authorization method Client will e-sign below (typed) Upload signed authorization Send authorization link to the client by emailClient typed full name (as signature)Upload signed client authorization (PDF/JPG)Choose File We will contact the client at the email provided above to confirm authorization for EA scheduling coordination. I confirm the client has authorized me to coordinate scheduling and administrative communication with STG Health Services Inc.PreviousGoal SettingPrimary goal for this concierge call- Select -Burnout recovery plan for a founder/ownerExecutive burnout / leadership resilience planSupport after a stress-related leave / return-to-workPerformance decline / decision fatigue / overwhelmTeam or organizational burnout (leadership consult)Not sure (please advise)What prompted this request right now?Any immediate risk flags we should know about?- Select -No immediate risk flagsSleep is severely disruptedPanic/anxiety spikesFrequent shutdown/crash daysIrritability/conflict escalating at work or homeSubstance use increasingRecent medical event / evaluationOther (explain below)If 'Other', please explainScheduling Window (Next 5 Business Days)Please provide a scheduling window. If you include multiple options, we can usually find a time faster.Availability in the next 5 business daysScheduling constraints / gatekeeping notesPreviousPayment & ConfirmationPaymentConcierge Consult fee: $250 Includes priority scheduling coordination and a 30-minute consult call. We will schedule the call within 5 business days (subject to availability). The $250 is credited toward the first intake session when booked within 14 days of payment.Concierge Consult FeeFee: $250.00Pay with Card (Stripe) This request is for Executive Assistants only. The Concierge Consult includes a 30-minute call scheduled within 5 business days (subject to availability). The $250 concierge fee is credited toward the first intake session if booked within 14 days of payment. The EA will receive a phone call within the next 24 hours to schedule the Concierce Call. This form is not monitored for emergencies. If there is immediate risk, call 911 or local emergency services. I acknowledge the Concierge Consult fee and policies above, and I confirm I am acting as the client's Executive Assistant for scheduling and administrative coordination. Previous Request Concierge Consult
