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Complete this form for Personal Coaching
Complete this short form to share the areas in which you feel stuck, overwhelmed, confused or anxious and you'll receive a call to learn more about how we can support you further.
20
Questions
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1
Name
First Name
Last Name
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2
Phone Number
Please enter a valid phone number.
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3
Email
example@example.com
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4
Date of Birth
-
Date
Year
Month
Day
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5
Where did you hear about Coaching with Lanasia Angelina?
Please Select
Google
Instagram
Facebook
Social Media Ads
Past Client/Friend
Please Select
Please Select
Google
Instagram
Facebook
Social Media Ads
Past Client/Friend
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6
If you heard about Lanasia from a referral source, please list their name
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7
Which areas of your life are you seeking support for transformation?
Select all that apply
Career/Business
Goal Setting & Accountability
Strategy & Planning
Relationships
Fitness/Personal Well-Being
Mindset/Emotional Management
Self-Confidence/Imposter Syndrome
Balance & Fulfillment
Purpose & Identity
Burnout/Overwhelm
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8
Explain in greater detail why you chose the answer(s) above?
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9
Select the word(s) that best describe how you often feel about the areas you selected for the previous question:
Stuck
Fearful
Overwhelmed
Worthless
Unqualified
Confused
Frustrated
Discouraged
Anxious
Demotivated
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10
Choose the best answer: On most days I feel...
Excited about my life and future
Discouraged about my life and future
Anxious about my life and future
Stuck and confused about my life and future
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11
Choose the best answer: When I think about my past I feel...
Excited
Discouraged
Anxious
Stuck and confused
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12
How long have you been experiencing these challenges?
3 months
1 year
6 months
longer than one year
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13
Rate your ability to overcome challenges
Please Select
Easily. Challenges don't stop me.
I could use some support.
Very difficult. Challenges stop me.
Please Select
Please Select
Easily. Challenges don't stop me.
I could use some support.
Very difficult. Challenges stop me.
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14
Rate your current level of personal fulfillment
Please Select
Very fulfilled.
Seeking more.
Not fulfilled at all.
Please Select
Please Select
Very fulfilled.
Seeking more.
Not fulfilled at all.
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15
Are you currently seeing /have you seen a therapist?
YES
NO
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16
Have you tried any other forms of support?
YES
NO
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17
Explain in greater detail how coaching can support you in your life and/or business:
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18
What's your budget for personal coaching?
Please Select
$500
$2500
$5000
$1000
Please Select
Please Select
$500
$2500
$5000
$1000
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19
Before scheduling an official consultation. You will be contacted to further discuss your needs. When is the best time to chat for 10-15 minutes over the phone?
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20
Are you interested in our financing options?
YES
NO
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