Inner Peace. Outer Beauty. Assessment Form

Thank you for taking the first step towards a deeper connection with yourself.

I look forward to connecting with you.

Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Area CodePhone Number

Date*

Date

1. To begin with, please list any medical conditions that you are currently taking any medication for?

Yes, or No?*

type Yes, or No.

2. Rate the following aspects of your life between 0-10, 0 being least satisfied with, and 10 = most satisfied.

Relationship with Romantic partner*

Relationship to children *

Relationship to friends *

Relationship to parents*

Type a question

Career/job/work *

Physical fitness *

Spirituality/Religion *

Physical appearance *

Emotional State*

3. Have you ever experienced any emotional or physical trauma or abuse? Yes, or No. *

If yes, pleasedescribe:

Has the issue been resolved? Yes, or No.

4. In what area of your life do you currently feel stuck? Tick all that applies.

Relationships

Career

Finances

Health/fitness

Physical Appearance

Emotional Wellness

5. In terms of Mirror Mirror coaching, I am looking for (tick all that applies):

Meaningful connection to myself

More self confidence in my appearance

More at ease with my emotions

Better communication with others

Better skin

Healthier lifestyle

More self-respect/self-esteem/self-worth

6. I want to clear obstacles in the following areas of my life (tick all that applies, or type yes):

Relationships

Health issues

Career/work

Finance

7. I use holistic products for my skincare and wellbeing:

Yes, No, or sometimes.*

What are they?

8. Are you willing to invest in transforming yourself?

Yes, or No.*

Thank you for your trust. I look forward to helping you uncover your inner peace and outer beauty.

Blessings,

Katrina

(plese email completed form to Valente.Kat@gmail.com)