True Self Health Coaching Questionnaire

True Self Health Coaching Questionnaire

Please take a couple minutes to answer the following questions to help us understand how we can best work together.
Upon completing this form, you will receive a follow up email with details on coaching options, packages, and a link to an optional discovery call to connect and answer any questions before beginning our work together.
PERSONAL DETAILS
Name*

First NameLast Name
Email*
example@example.com
Where are you located?*
COACHING INFORMATION
What is the main issue(s) that I can help you with? *
What interests you most about the connection of breathwork, stress, pain, mind-body connection, and other lifestyle-health practices?*
How do you feel that our work together can support you in accomplishing your goals?*
On a scale of 1 to 10, how much stress do you experience on a daily basis?*

1

2

3

4

5

6

7

8

9

10

1 is Minimally Stressed, 10 is Severely Stressed
On a scale of 1 to 10, how would you rate your quality of breath?*

1

2

3

4

5

6

7

8

9

10

1 is Very Poor, 10 is Excellent
On a scale of 1 to 10, how would you rate your overall quality of health?*

1

2

3

4

5

6

7

8

9

10

1 is Very Poor, 10 is Excellent
What are the primary factors that you feel contribute to your current state of stress, breath, and health (or lack of breath/health)?*
Please describe an ideal outcome that you aim to achieve in working together?*
How would you describe your relationship to your 'True Self'? (Mind, Body, Health, Heart, Purpose, and Spirit)*
Please include anything else that you would like to share:*
COACHING PACKAGES:

5-Week Reset - 5 Weekly Sessions aimed to support you in resetting your mind-body and nervous system.
3-Month Growth* - Looking for continuous growth and support? This is a great plan that builds on the foundation of breath.
6-Month Transformation* - This program is for those looking to take their practices to another level. Transform in mind, body, spirit. I got you.

3 & 6-Month Packages includes premium access to online courses, our online community, and more!
What coaching package are you interested in?*

6-Month Transformation Package3-Month Growth Package5-Week Reset PackageNot Sure Yet
More information on packages will be sent in the follow up email along with a link for a discovery call if you'd like to discuss anything with Justin before making your payment.
Thank you for trusting me with the opportunity to work together. I look forward to connecting with you, learning about your story, and supporting you on your journey towards your truest version of self.

— Dr. Justin Ternes
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True Self Health Coaching Questionnaire

PERSONAL DETAILS

COACHING INFORMATION

COACHING PACKAGES: