1:1 Work With Me Application 2026

SECTION 1: PERSONAL DETAILS

Let’s begin with your basic details so I know how to contact you and understand a little of your current context.
First Name
Last Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Location

Street Address

Street Address Line 2
Postal / Zip CodeCountryCityState / Province

What kind of work, business, leadership role, creative practice, or life season are you currently in?
How did you find me or hear about my work?
Have you attended any of my classes, breathwork sessions, workshops, programs, retreats, or events before?
If yes, please share what you have experienced.

SECTION 2: WHAT IS BRINGING YOU HERE

This section helps me understand what has led you to apply for private coaching at this point in your life.
What inspired you to apply for 1:1 coaching at this point in your life?
What is currently feeling heavy, hard, stretched, unclear, or out of alignment for you?
What do you feel you are carrying that you are ready to understand more deeply?

SECTION 3: PATTERNS, STRESS + NERVOUS SYSTEM

This work often begins by noticing the patterns, responses, and body signals that have been shaping the way you move through life.
Are there any repeated patterns you are beginning to notice in your life, relationships, work, body, or nervous system?
For example: over-responsibility, people-pleasing, perfectionism, avoidance, emotional shutdown, urgency, control, self-doubt, anxiety, burnout, difficulty resting, difficulty receiving, or feeling like you are always holding it together.
How do you currently cope with stress, pressure, conflict, emotional overwhelm, or uncertainty?
What tends to happen in your body when you are under pressure?
For example: tension, fatigue, shallow breathing, racing thoughts, collapse, numbness, irritation, urgency, tears, shutdown, tight chest, stomach discomfort, or difficulty sleeping.

SECTION 4: SUPPORT, HISTORY + CURRENT CARE

This section helps me understand what support you currently have, what you have explored before, and what feels important for me to know before we connect.
Are you currently working with any other coaches, therapists, counsellors, doctors, healers, mentors, or practitioners?
If yes, please share who is currently supporting you and in what way.
What have you explored before in relation to healing, therapy, coaching, self-development, breathwork, nervous system work, embodiment, or personal growth?

What has supported you?
What has not felt helpful, sustainable, safe, or effective?
Is there anything important for me to know about your current emotional, mental, physical, relational, or life circumstances before we connect?
Please only share what feels appropriate at this stage.

SECTION 5: DESIRE, DIRECTION + CHANGE

This section helps me understand what you are longing for, what you want to feel more of, and what meaningful change would look like for you.
If you could shift one thing about how you feel day-to-day, what would it be?
What are three qualities, states, or experiences you would love to feel more of in your life?
For example: steadiness, clarity, confidence, softness, trust, capacity, emotional freedom, self-respect, ease, pleasure, courage, safety, connection, direction, or presence.
Do you have any specific goals related to stress, anxiety, nervous system regulation, emotional capacity, relationships, leadership, self-worth, boundaries, breath, or embodiment?
What would meaningful change look like for you after three months of working together?
What would success feel like in your body, not just look like on the outside?
Why do you feel I may be the right coach, practitioner, or mentor for you?

SECTION 7: FINAL REFLECTION

Please share anything else that feels relevant before we begin the conversation.
Is there anything else you feel it is important for me to know about you, your current situation, or what you are hoping for before we connect?
SECTION 8: CONSENT + SUBMIT
Should be Empty:

INTRODUCTION / WELCOME SECTION: