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Name
First Name
Last Name
Phone Number
E-mail
example@example.com
First Time Session?
Yes
No
Occupation ( whatever you spend the most time doing)
What are the top three goals you want to achieve with my coaching?
How would you describe your current level of confidence on a scale of 1-10?
This includes your confidence with making decisions, communication with loved ones or at work, using discernment with interactions, trusting your intuition, etc.
Do you feel like people are staring at you when you walk into a room?
Yes, I feel like this constantly
No, I never consider that
I'm not sure, but I do wonder
Don't know, don't care
How often do you feel overwhelmed or stressed out?
Constantly
Often
Sometimes
Never
What are your biggest fears/anxieties?
Describe a situation in which you felt empowered:
Describe a situation in which you felt embarrassed or uncomfortable:
What do you love most about yourself?
What areas of your life do you feel need the most improvement?
How do you typically handle being faced with setbacks or roadblocks?
What does self-care look like to you?
How (if at all) do you prioritize self-care in your daily routine?
What negative beliefs do you have about yourself?
Can you identify any patterns in your relationships or interactions with others? If so, list some:
How do you typically handle criticism/feedback?
Can you identify what experiences have shaped your current self-images?
Describe your current support system in one word:
Do you celebrate your achievements? If so, how?
Have you worked with a life coach/advisor before?
Yes
No
If so, share both what you liked and disliked about the experience:
What is one thing you would change about your life right now (if you could)?
On a scale of 1-10, how committed are you to making changes in your life?
Please use this space to share anything that may help me to better understand you or anything you think it may be useful for me to know during our potential advisory relationship:
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