Coaching Intake Form

1
What type of coaching are you wanting today?* This field is required.
Please Select
Please Select
Wellness
Mindset
Both
2
How would you describe yourself right now?* This field is required.Goal Setting Select all that apply.
I need help with planning out my goals.
I know my goals and how to execute them, but I need motivation to do so.
I need help figuring out my wellness goals.
I am someone who likes having an accountability partner to reach my goals.
I want to improve my mindset and/or wellness, but I don't know where to start.
3
How would you describe yourself?* This field is required.Goal Execution Select all that apply.
I am someone who likes to-do lists.
I am someone who prefers weekly goals over daily goals.
I prefer to plan out daily goals and not weekly goals.
I have a vision board.
I don't have a vision board, but I would like to create one.
I like using a planner or calendar to organize my schedule.
I use an app or someone to keep me accountable to reach my goals.
I prefer to plan out long-term goals but not short-term goals.
I am someone who prefers to plan out short-term goals but not long-term goals.
I don't like to plan in advance.
Planning stresses me out.
4
Describe yourself as best as you can.* This field is required.
Introverted
Extroverted
More introverted than extroverted
More extroverted than introverted
I'm not sure.
5
On a scale from 1-10 with 10 being the best it's ever been, how satisfied are you with your life right now?* This field is required.Think about the 8 pillars of wellness: Emotional, Financial, Social, Spiritual, Career/Occupational, Physical, Intellectual, Environmental
6
How can we help you feel 100% satisfied with your life? * This field is required.In other words, why did you choose to sign up for coaching?
Huge
Large
Normal
Small
Ok
Ok
7
Briefly describe a moment in your life where you had to pivot and adapt to a new situation or challenge.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
8
Our coaching program consists of goal setting based on your individual needs. Is this something you are interested in?* This field is required.
YESNO
9
In our coaching program, we focus on your mindset and wellness goals only. Is this something you are okay with?* This field is required.If we see something is outside of our reach, we will refer you to the proper resources.
YESNO
10
Our One on One Coaching Packages
11
Which coaching package are you interested in?* This field is required.
Ignite and Renew Your Potential: 4 sessions
Elevate and Transform: 6 sessions
Empower and Succeed: 8 sessions
I need help figuring out which one is best for me.
12
Thank you for answering those questions :) Please fill out your information below. * This field is required.
First Name
Last Name
13
Email* This field is required.
example@example.com
Confirm Email
14
Select an appointment time for your free 15-minute intake session.* This field is required.
Should be Empty: