AlQuemi Holistics
1:1 Mindfulness Coaching
Name
First Name
Last Name
Birth Date
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Phone Number
Format: (00) 000-000000.
Email
example@example.com
Country
How would you like your coaching delivered?
Online
Personal
What would you like to achieve?
What is stopping you from achieving your goals?
Questionnaire
Rows
Yes
No
Do you smoke?
Do you drink alcohol?
Are you using any additional vitamin or supplements?
Do you meditate?
Do you have a fitness plan?
Do you incorporate flexibility stretching in your days?
Your stress levels in the past month?
Never
0
1
2
3
4
Always
5
0 is Never, 5 is Always
Have you previously worked with a Mindfulness Coach?
Yes
No
Please select the reasons you feel you need coaching.
Reducing stress
To find my purpose
Getting rid of an attachment
Spiritual guidance
Incorporate mindfulness in my life
Increasing motivation
Submit
Should be Empty: