New Client Health and Lifestyle Questionnarie

1

Welcome

You'll be guided through 50 questions about yourself—this helps me get a clear understanding of your needs and situation. Please take your time to answer them as thoroughly as possible.

Once you’ve submitted your responses, I’ll review them and either approve or decline your application to work with me. A decline simply means I feel you may benefit more from a different approach or that this may not be the right time for us to work together. Either way, you'll receive an email update.

If approved, you’ll be invited to book an initial 30-minute consultation for £88. After this, if you're happy with the service and wish to continue, we can arrange further consultations at the current hourly rate of £333.33.

This process ensures that your well-being, time, and the quality of my services are respected—allowing me to support you in the best possible way. Looking forward to connecting with you! 😊
2
What is your first name?* This field is required.
3
Last name* This field is required.
4
What would you like to be called?* This field is required.
5
AddressPlease enter your full address and post code
Huge
Large
Normal
Small
Ok
Ok
6
E-mail* This field is required.
example@example.com
7
Mobile phone
Country Code
Area Code
Phone Number
8
Referred by (optional)How did you hear about me and my services?
9
Congratulations on taking a very important step in your life!

This questionnaire contains some powerful questions for you to consider before your first coaching session. This tool is meant to empower you to think clearly, become intentional and allow yourself the privilege to look for the answers. Think about what you want, what limitations you’re currently living with, and how you can move forward into the life you desire living.

To make the most of this session, I invite you to find 45 min to 1 hour where you can have an appointment with yourself, uninterrupted. Find an environment that is relaxing, pleasing and allows you to be at your best, 100% focused on yourself. Give yourself the gift of time. Allow your answers to come from your whole engaged being.

Use this tool anyway you would like. Take some time to ponder the questions, answering all the questions or choosing not to.

I hope that you will make a choice to be open to all possibilities.
10
What do you most want to achieve from working with me?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
11
What 3 changes do you most want to make in your life?* This field is required.Please give at least 3 answers.
12
And are you ready to achieve these changes?* This field is required.Please select 1 answer.
Please Select
Please Select
Yes
Yes, with help I can
Maybe
No
13
As an adult, have you ever worked in a one-on-one relationship (e.g., tennis coach, piano teacher, and therapist)?* This field is required.Please select 1 answer.
Please Select
Please Select
Yes
No
14
If yes, what worked well for you? What did not work well? * This field is required.
15
Have you experienced any major changes in the past two years? If so, list them below.* This field is required.(ie.. change of job, a new role, change in residence, divorce, health changes etc.)
16
On a scale of 1-10 (10 being the highest), how fulfilled are you with the choices you’ve made in the last 6 months?* This field is required.
Please Select
Please Select
1
2
3
4
5
6
7
8
9
10
17
Is there anything you are just tolerating in your life at present? (Examples: clutter, overdue bills, job dissatisfaction, dead plants, overeating, broken equipment, etc)* This field is required.
18
Do you have any concerns about life at present?* This field is required.If so, please explain below.
19
What causes you to feel motivated?* This field is required.
20
What is your personal and/or professional vision?* This field is required.Tell me who you would like to be in your personal and/or professional life.
21
Do you currently have any goals in your life?* This field is required.If so, please state your most pressing goal.
Huge
Large
Normal
Small
Ok
Ok
22
When would you realistically like that goal to be achieved by?* This field is required.
Date
Month
Day
Year
23
On a scale of 1-10 (10 being the highest), what is the quality of your life today??* This field is required.
Please Select
Please Select
1
2
3
4
5
6
7
8
9
10
24
How do you feel about your physical health, including weight, immune system, and energy level?* This field is required.
25
Describe your physical fitness, wellness and exercise habits.* This field is required.
26
How would you describe your sleeping habits?* This field is required.For example: good/poor/regular/irregular/etc.
27
Do you feel that you are in tune with your body and do you listen to what your body needs?* This field is required.If so, please explain below.
28
Do you have any underlying illnesses?* This field is required.If so, please explain below.
29
Do you take any supplements and/or medication?* This field is required.Please list all supplements, medication and the frequency and dosage for each below.
30
Have you taken any COVID-19 shots? If so, would you mind sharing how many and which types?* This field is required.Please list all COVID-19 vaccines you have taken, the types and when you had them.
31
Do you have any allergies, including medication allergies?* This field is required.If so, please list below.
32
What do you typically eat in a day?* This field is required.Please provide an outline of food, drink and times of consumption throughout your average day.
33
How do you feel about the way you eat? Are there any changes you would like to make?* This field is required.
34
How would you describe your relationship with food?* This field is required.
35
How do you feel when you meet new people?* This field is required.
36
Describe your social life. If any, what kinds of activities do you participate in?* This field is required.
37
How do you feel your communication is with others?* This field is required.
38
Are you an honest person?* This field is required.
39
Are you a good listener?* This field is required.
40
When you are faced with obstacles and challenges, how do you react?* This field is required.
41
How easy do you find expressing your feelings?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
42
How do you manage stress, including which activities you turn to when stressed?* This field is required.
43
Do you have any diagnosed mental health conditions?* This field is required.If so, please explain below.
44
Do you happen to know your Myers-Briggs personality type?* This field is required.
Please Select
Please Select
ESTJ
ENTJ
ESFJ
ENFJ
ISTJ
ISFJ
INTJ
INFJ
ESTP
ESFP
ENTP
ENFP
ISTP
ISFP
INTP
INFP
I do not know
45
Do you participate in any regular spiritual practices?* This field is required.
46
How do you feel about your spiritual practices and spiritual life?* This field is required.Please skip if you answered no to the previous question.
47
Do you believe in a higher power? If so, what does your higher power mean to you?* This field is required.
48
Overall, how would you rate your physical health?* This field is required.
1
2
3
4
5
6
7
8
9
10
Worst
Best
49
Overall, how would you rate your mental health?* This field is required.
1
2
3
4
5
6
7
8
9
10
Worst
Best
50
Overall, how would you rate your social health?* This field is required.
1
2
3
4
5
6
7
8
9
10
Worst
Best
51
Overall, how would you rate your spiritual health?* This field is required.
1
2
3
4
5
6
7
8
9
10
Worst
Best
52
Is there anything else you would like to share with me?
Should be Empty: