True Self Pain & Physiotherapy Application

True Self Pain & Physiotherapy Application

Thank you for your interest in our True Self Health 1:1 Coaching.
The information you provide will help us understand how to best support you in reaching your health and performance goals.

Please set aside 15 - 20 minutes of intentional space to respond to these questions. This is an opportunity for self-reflection and to see if working together feels like a good fit for us both. All answers are confidential.
PERSONAL DETAILS
Name

First NameLast Name
Email
example@example.com
Where are you located?
CLIENT INFORMATION
What is the main issue(s) that I can help you with?
How is this negatively impacting your quality of life?
What are the top 3 outcomes you're looking to gain from working together?
How do you feel that our work together can support you in accomplishing your goals?
On a scale of 1 to 10, how stressed do you feel on a daily basis?

1

2

3

4

5

6

7

8

9

10

1 is Minimally Stressed, 10 is Severely Stressed
What are the primary factors that contribute to your stress?
On a scale of 1 to 10 how important is it for you to improve these stressors?

1

2

3

4

5

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8

9

10

1 is Not at all important, 10 is With all my heart
How would you describe your relationship to your 'true self'? (In Mind, Body, Health, Heart, Purpose, and Spirit)
Where would you like to see yourself in the next year?
What kind of guidance or assistance do you respond to best? What would help you feel most empowered as we work together?
Is there anything else you would like me to know? Please use this space to share anything that you feel would be helpful and supportive to this journey.
Please acknowledge that while I am a licensed physical therapist, our work together is conducted in a coaching capacity. This coaching is focused on mind-body connection, pain science, breathwork, stress regulation, and metabolic health practices, rather than medical diagnosis or treatment. By clicking below, you confirm your understanding that, although I am a Doctor of Physical Therapy, my role in this context is non-medical. The guidance provided is intended for general health and wellness coaching and is not a substitute for professional medical advice, diagnosis, or treatment. For specific health concerns, please consult your healthcare provider.

I understand and agree
Thank you for trusting me with the opportunity to work together. I look forward to connecting with you and learning about your story.

— Dr. Justin Ternes
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True Self Pain & Physiotherapy Application

The information you provide will help us understand how to best support you in reaching your health and performance goals.

PERSONAL DETAILS

CLIENT INFORMATION