MENTORING CONSULTATION

Thank you for considering working together. This form helps me understand where you are in your journey and how I might best support you in creating lasting change.
Name*

First NameLast Name
Pronouns (She/Her, He/Him, They/Them, Combo)*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Preferred Contact Method:*

TextCallEmail
Where You Are Right Now
What's bringing you to mentoring at this point in your life?*
On a scale of 1-10, how would you rate your current stress levels:*
On a scale of 1-10, how would you rate your current energy levels:*
On a scale of 1-10, how would you rate your current confidence levels:*
On a scale of 1-10, how would you rate your current satisfaction levels:*
What is/are your biggest challenge(s) right now?*

Chronic stress/overwhelmInconsistent healthy habitsSelf-sabotaging behaviorsLack of energy/motivationFeeling stuck in old patternsNot knowing where to startOther
If other, please explain:*
What You've Already Tried
What approaches to stress management or habit change have you tried before?*

Self-help books/podcastsMeditation/habit appsTherapy/counselingFitness programsDiet changesSupplements/wellness productsOther programs/coursesThis is my first attempt
What worked (even a little)?*
What didn't work or felt unsustainable?*
What made previous attempts challenging?*

Lack of consistencyToo overwhelming/complicatedLife circumstances got in the wayDidn't see results quickly enoughFelt like I was doing it "wrong"Lacked accountability/supportOther
If other, please explain. Or, you may use this space to share further details.
Your Goals & Hopes
What would you most like to change or improve?*

Better stress managementMore consistent self-careImproved energy & focusHealthier relationships with food/substancesBetter sleep & restMore confidence & self trustBreaking self-sabotaging patternsOther
If other, please explain: *
If we worked together successfully, what would be different in your life 3-6 months from now?*
What would make this mentoring experience feel worth the investment for you?*
Your Learning Style & Needs
What kind of support do you most need? Check all that apply:*

Someone to help me understand why I do what I doAccountability to stick with changesSupport when I'm struggling or stuckHelp creating realistic, sustainable plansRegular check-ins and accountabilityEncouragement to trust myselfOther
How ready are you to examine patterns that aren't serving you:

VerySomewhatNot sure
How ready are you to try new approaches to self-care:

VerySomewhatNot sure
How ready are you to commit time and energy to change:

VerySomewhatNot sure
Practical Considerations
How much time can you realistically commit to this work?*

30 Minute per week1 Hour per week2-3 Hours per weekDepends on the weekNot sure
What time of day/week works best for you?*

Weekday morningsWeekday afternoonsWeekday eveningsWeekend morningsWeekend afternoons
Investment considerations:*

I'm ready to invest in meaningful changeI need to understand costs before decidingCost is a significant concern for me
About You
What else would be helpful for me to know about you, your life situation, or what you're dealing with?*
Any concerns or questions about working together?*
What drew you specifically to my approach?*
Thank you for taking the time to share with me.

After I receive your form, I'll reach out within 48 hours to explore whether we're a good mutual fit and how I might best support your healing.
Should be Empty:

Where You Are Right Now

What You've Already Tried

Your Goals & Hopes

Your Learning Style & Needs

Practical Considerations

About You