• Coaching & Transformative Imagery Matching Questionnaire

    This brief questionnaire helps NeuroTransform match you with a health coach and/or guided imagery practitioner who is a good fit for your goals, preferences, and availability. It is not a diagnostic or medical form and it is not reviewed for emergency, diagnostic, or treatment purposes. Its purpose is simply to help us understand what you’re looking for so we can recommend the right practitioner and approach for you.

  • Contact Details

  • Goals and Practitioner Preferences

  • What are you interested in today?*
  • What are your primary goals right now?*
  • For example, you might have preferences around communication style (gentle vs more direct), personality, lived experience, or areas of interest (such as stress, performance, behavior change, or lifestyle habits). If it feels important, you can also mention any background or perspective you’d feel most comfortable with.
  • Have you worked with any of the following before?*

  • Readiness and Comfort

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  • Practical Considerations

  • General availability (check all that apply):*
  • Preferred session format:*
  • You’re welcome to share anything that feels relevant (for example, energy levels, pain, sleep issues, or other factors you’d like your coach or practitioner to keep in mind). Please don’t include detailed medical records here—if needed, your coach or practitioner can explore this with you in more depth.

  • Agreement about Scope

  • This form is hosted by Jotform, a third-party form platform used by NeuroTransform to collect form submissions.

    NeuroTransform provides wellness, educational, coaching-style, and guided imagery support and referral resources only. NeuroTransform’s support and resources, as well as health coaching and guided imagery services provided by independent coaches or practitioners, are educational and supportive in nature and are not medical care, psychotherapy, diagnosis, treatment, crisis services, or emergency support. They are not a substitute for care from a licensed healthcare or mental health professional. Coaches and practitioners do not diagnose, treat, or prescribe. If you have medical or mental health concerns, please consult a licensed provider.

    Referral partners are independent practitioners or businesses. NeuroTransform does not control, supervise, guarantee, or assume responsibility for their services, advice, credentials, licensure, availability, fees, or outcomes.

    NeuroTransform may receive compensation from certain independent practitioners or referral partners. No such compensation creates a medical, mental health, fiduciary, or professional provider relationship between NeuroTransform and the client, and does not guarantee any result.

    Please do not submit urgent, crisis-related, or highly sensitive medical information through this form. If you are experiencing a medical or mental health emergency, thoughts of self-harm, or a crisis, do not use this form. Call 911, 988, or seek immediate help from a qualified professional or emergency service.

    Information you submit will be used to respond to your inquiry, evaluate fit for services or referrals, and communicate with you, consistent with our Privacy Policy. Because this is a matching questionnaire, NeuroTransform may share relevant information from your responses with independent coaches or practitioners to determine availability and fit. Your information will not be shared for other purposes except with your permission or as required by law.

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