One on One (1:1) Private Wellness Coaching Application

Private Wellness Coaching Application
Name

First NameLast Name
Are you over the age of 18?
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
State of Residence
Current Situation
I am...
Therapy and Mental Health
Are you currently under the care of a therapist or mental health professional for any diagnosed mental health conditions?
Have you previously been diagnosed with a mental health condition or received treatment in the past?
Obstacles and Motivation
What has been your biggest obstacle when it comes to moving towards improving your relationships with your thoughts and emotions?
What has motivated you to apply for private coaching to improve your relationship with yourself and God?
Mindset and Support System
Describe your mindset when it comes to doing the inner work.
What does your support system currently look like? (i.e. supportive, indifferent)
Faith and Spirituality
Do you have a faith-based or spiritual practice that grounds you? If yes, please provide details. If no, would you be open to learning more about biblical principles and teachings?
Have you received coaching in the past?
Past Journey and Learning
What tools have worked for you in the past during your personal growth journey?
What tools HAVE NOT worked for you in the past during your personal growth journey?
Commitment and Accountability
How likely are you to attend every session fully prepared and ready to learn?

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1 is Least likely, 5 is Definitely
How do you handle setbacks or obstacles when working towards a goal?

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5

1 is Terribly, 5 is Very Well
Openness and Responsiveness:
How willing are you to trust the coaching process?

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1 is Unwiling, 5 is Very Willing
How willing are you to complete the necessary work/assignments?

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1 is Unwilling, 5 is Very willing
If you find it difficult to keep up with sessions or homework, what kind of support or accountability do you feel you need to be successful?
Feedback and Modifications
Are you open to receiving feedback?
Are you open to making modifications to your approach as needed?
Commitment and Ideal Coaching Situation
Are you willing to commit to 2-3 months of private coaching?
What is your ideal coaching situation?
My goal as your wellness coach is to mentor and guide you towards achieving a state of complete wellness and wholeness. I am dedicated to assisting you and attaining overall emotional, spiritual, and mental well-being. While I am here to provide support and direction as your coach, it is important to clarify that I am not here as your therapist and will not make decisions for you. Do you have any reservations about this?
Which Private Wellness Coaching Program costs options works for you?
How did you hear about me?
Should be Empty:

Current Situation

Therapy and Mental Health

Obstacles and Motivation

Mindset and Support System

Faith and Spirituality

Past Journey and Learning

Commitment and Accountability

Openness and Responsiveness:

Feedback and Modifications

Commitment and Ideal Coaching Situation