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Wellness & Relationship Coaching Application

Please fill out this questionnaire to help us understand your needs and goals in wellness, fitness, nutrition, and relationship coaching for women pre and post-divorce.
Full Name*

First NameLast Name
Email Address*
example@example.com
Phone Number
Please enter a valid phone number.
What are your main wellness goals? (e.g., fitness, nutrition, mental health)*
What relationship challenges are you currently facing or want to address?*
Are you currently pre-divorce or post-divorce?*

Pre-divorcePost-divorceNot marriedHappily marriedWould like some relationship guidanceOther
Which areas are you interested in coaching?*

FitnessNutritionMental HealthRelationshipOther
Please share any additional information or specific concerns you have.
What are your main goals for relationship coaching?*
What are your main goals for fitness coaching?*
What are your main goals for nutrition coaching?*
Please provide your health history, including any chronic conditions, allergies, or recent surgeries.*
Are you currently taking any medications? If yes, please list them.*
Do you have any physical limitations or injuries we should be aware of?*
Have you ever been diagnosed with any mental health conditions? If comfortable, please share details.*
Please describe your lifestyle habits (e.g., exercise frequency, diet, smoking, alcohol consumption).*
How long have you been thinking about coaching?*
What is it about coaching that has interested you? Have you ever had coaching before?*
What does your daily diet look like?*
Are you aware of the estimated calories you consume?*
Are you interested in learning more about nutrients, such as micronutrients and macros?*
What areas would you like to focus on during coaching?*

Relationship BuildingStress ManagementPhysical FitnessNutrition & DietMental WellnessWeight ManagementSleep ImprovementOther
What are your preferred coaching styles?*

One-on-one sessionsGroup coachingOnline coachingIn-person coachingSelf-paced learningWorkshops & Seminars
In-Depth Coaching Interests*

FitnessNutritionRelationshipPosttraumatic StressTraumatic RelationshipDaily Activity LevelOccupationPatient StatusEstimated Daily StepsEstimated Water ConsumptionHobbiesOther
What does your weekly and daily schedule look like? Please include any details about your children, pregnancy status, and family planning.
Family History Questionnaire

Do you have children?How many children do you have?Are you currently pregnant?Did you just have a baby?How old are your children?Do you want children?Other
Please provide any additional information about your family history, habits, or activities that make you happy.
Are you currently practicing a self-care routine or habits? Please describe.
Participant Signature*

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Emotional Fitness & Mindset TransformationCourse Overview: Do you ever feel embarrassed, self-conscious, or “behind” when it comes to taking care of yourself — especially your emotional or physical wellbeing? You’re not alone. Many women carry quiet shame around starting over — whether it’s returning to the gym, setting boundaries, or just admitting that you’ve been running on empty. This course was created for the woman who’s ready to rebuild from the inside out — to reconnect with her confidence, body, and emotional strength without judgment, pressure, or guilt. Through evidence-based mindset tools, emotional regulation techniques, and gentle psychology-driven exercises, you’ll learn how to: Release shame around your body, energy, and emotions Reprogram self-critical thoughts into empowering beliefs Build inner and outer confidence — one small step at a time Create emotional fitness habits that sustain real transformation
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Please sign to confirm the information provided is accurate.*

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Liability Waiver and Acknowledgment*
I hereby acknowledge that the coach and coaching services provided are not responsible for any physical, mental, or emotional injury or damages that may arise. I waive any claims against the coach and understand that coaching is not a substitute for professional medical or psychological treatment. I agree to hold the coach harmless from any liability arising from my participation in coaching sessions.
Client Responsibility and Liability Waiver*
I acknowledge that I am responsible for participating as fully as possible in coaching sessions to achieve the best results. I understand that adherence and active participation are crucial to my progress. I agree to exercise due diligence and take responsibility for my own actions during the coaching process. I waive any liability from the coach for outcomes resulting from my level of participation or adherence. Please note the importance of scheduled coaching appointments. If you need to cancel an appointment, please contact your coach. If you are unable to make it within 24 hours of the appointment, no-show fees may apply. Taking coaching seriously includes completing tasks, modules, homework exercises, journaling, data gathering, and reaching out to your coach for follow-up requests. Adherence to these practices is vital for your success and achieving greater results from the coaching services.
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Wellness & Relationship Coaching Application