The AlignedBEing Kickstart Questionnaire

The AlignedBEing Kickstart Questionnaire
This questionnaire contains some questions for you to explore and answer for your Total BEIng Kickstart Session. The first part of this tool allows me gather your medical history quickly. The second part is a tool meant to empower you to think clearly and identify where you are and where you are meant to be. I welcome you to become intentional, open yourself up to possibilities, and give yourself the space to look for the answers.

Just a reminder that there are no wrong or right answers- just your experience and your desires- which are all valid!

The purpose of this questionnaire is so that our 2 hours together are as efficient and effective as possible.

**TRUST ME- Our session will be SOOO much more interesting if we don't have to go through all these questions in person.**

NB- All your information is confidential

You will receive a copy of your completed form for your future reference.
Name

First NameLast Name
Date of birth

MonthDayYear
Occupation

Past Medical History
List your full history with any and all physical injuries or accidents (explain in detail if able):
List any professionals you have seen for the above injuries or accidents, including the type of professional and the timeframe:
Have you been diagnosed with a mental or physical health condition? eg heart issues, high blood pressure, high cholesterol, low iron, low liver enzymes, depression/ anxiety, bipolar etc
Are you on any medication or supplements currently? Please list them below

Trauma History

For this section, share as much or as little as you’d like. Some questions may not apply to you, so feel free to leave blank.
1) Is there a history of sexual abuse, assault or harassment? Feel free to expand if comfortable.
2) Is there a history of physical abuse? Feel free to expand if comfortable.
3) Is there a history of emotional or verbal abuse? Feel free to expand if comfortable.
4) List any professionals you have seen for any above sexual, physical, emotional or verbal abuse, including the type of professional and the timeframe:

WHERE YOU WANT TO BE

Think about what you want and the life you desire to live. I welcome you to bring your FULL self forward. Don't be afraid to dream a bit!
1) What would you like your health, well-being, and life to look like 90 days from now? How about 6 months days from now? How would you feel if you got this result?
2) What do you hope to get out of our time together? If you could achieve at least 1 goal from our sessions, what would it be?
3) Why is it important for you to achieve these things?
4) On a scale of 1-10, how important is it for your to achieve your 6-month goal above?
5) How coachable are you?
6) What are 5 things you LOVE about your life?
Should be Empty:

	1	2	3	4	5	6	7	8	9	10
1) How do you feel about joy currently in your life?
2) How do you currently feel about your time?
3) How calm/ peaceful/ in control do you feel daily?
4) How peaceful/calm/in control do you feel daily?
5) How do you feel about your current personal relationships?
6) How do you feel about your current professional relationships?
7) How healthy/well do you feel on a scale of 1-10?
8) How connected with yourself and others do you feel on a scale of 1-10
9) How content in your career/ business do you feel?

	1	2	3	4	5	6	7	8	9	10
The fact that I have not been able to exercise or do recreational activities lately has been causing me distress.
I am not happy about the huge investment that my career or another aspect of my life has been lately.
I know all of the aspects that I would like to have included in my ideal life and some of them are definitely missing
My close family members, significant other, or friends have recentlytold me that I am overwhelmed in certain areas and neglecting others.This really bothers me and I think it’s true.
I often have thoughts like, “I wish I was able to do more of...”
I have always wanted to do several important things, but am not able to do any of them right now because there simply is not time in the day.
I find that I get frustrated often because I am not able to spend time with my family/friends or have some time for myself.
On a typical day, I feel uninspired and I lack energy to do what I need to get done.
I often feel like I am missing out on the things that mean the most to me.
It is typical for me to think that I have made poor decisions about how to invest my time and energy.
I frequently think, “wouldn’t it be amazing if I could do more of the things that bring me the most satisfaction or joy?”
I do not feel in control of my life or future.
I am not really sure what my priorities are right now, so I find myself trying to do too much.
Since I am trying to do too much, I end up sacrificing areas that could impact on my health, such as sleep, proper nutrition, or exercise.
I often find that I am focusing a lot more of my time and energy on one aspect of my life than I would like.
Given my current priorities in life, I feel I am making a sacrifice right now.

The AlignedBEing Kickstart Questionnaire

Past Medical History

Trauma History

WHERE YOU ARE NOW

Vision, mission, and values

WHERE YOU WANT TO BE