M.E.N. Client Form

1

Name

First Name

Last Name

2

Email

example@example.com

3

Phone Number

Please enter a valid phone number.

4

How's Your Finances?Take into consideration your income, bills and debt.

Couldn't be better.

Good but needs a little work.

Living paycheck to paycheck.

I'm drowning!

5

How's Your Relationships?This includes romantic, family and platonic relationships.

I have fulfilling relationships that lift me up.

I've got a few meaningful relationships but there are people that bring me down.

I'm surrounded by toxic people.

I completely isolate.

6

How's Your Spirituality?Not talking religion, but your connection to your place in this world.

I am truly connected with my place in the universe.

I know there's something out there, but not really sure what it is.

I've been struggling to find my spirituality.

There's nothing out there. Everything is coincidental.

7

How's Your Physical HealthTake into consideration your eating and physical activity habits.

I'm in peak physical health.

I'm in good shape, but could use a little push over that plateau.

I eat pretty well but need to get to the gym.

I get to the gym once in a while but my diet is crap.

I can't even look in the mirror right now.

8

How's Your Mental Health?

My mind is always clear and focused.

I've got my ups and downs but nothing unusual.

I have longer periods of fear, anxiety, stress and depression.

I am in a state of constant fear, anxiety, stress and depression.

9

Describe Your Life as You See it Now.Go into more detail about the areas of your life you would like to see improvement.

10

How Would You Like Your Life to Look?Describe some of your goals and create a picture of what you would like your life to look like.

11

Have You Ever Worked with a Personal Development Coach Before?

YESNO

12

If Yes, Please Describe Your Experience.If No, please type N/A.

13

If Working with a Personal Development Coach Could Help Improve Your Situation, Would You Invest in Yourself?

YESNO