Coaching Pre-Assessment Questionnaire
Thank you for completing this questionnaire and sending it to me ahead of our appointment. It will help me get to know you a little better before we meet. All information you share here and in our sessions is treated with complete confidentiality.
Name
*
First Name
Last Name
E-mail
*
example@example.com
Is it ok to add this email to the mailing list? (I send monthly tips to help with emotional eating, recipes and info on upcoming workshops - no spam)
*
Yes
No
Phone Number
*
-
Area Code
Phone Number
How long have you been struggling with food and/or your body image?
*
How would YOU describe your problem?
*
If I could wave a magic wand, how would you like your life to look like in 12 months’ time?
*
Have you sought help with this before?
*
Yes
No
If you answered 'Yes', can you tell me what type of help, for how long, and if you felt it helped or not?
...and if it didn't help, why do you think it didn't?
On a scale of 1-10, how motivated are you now to truly tackle and overcome this issue?
*
Not motivated
1
2
3
4
5
6
7
8
9
100% Committed
10
1 is Not motivated , 10 is 100% Committed
What would it mean to you to overcome your struggle with food, emotional eating and body image and move on with your life, free of all the stress associated with this issue?
*
Finally, is there anything else you would like to add for me to see ahead of our appointment?
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