Coaching & Transformative Imagery Matching Questionnaire

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; 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
Full Name

First NameLast Name
Email Address
example@example.com
Goals and Practitioner Preferences
What are you interested in today?
What are your primary goals right now?

Other (please describe)
Please share a bit more about your goals in your own words.
What would a good‑fit practitioner look like for you? (Optional)
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?
If yes, what felt most helpful or unhelpful about that experience?
Readiness and Comfort
On a scale of 1–10, how ready do you feel to explore this work or make changes right now?

1

2

3

4

5

6

7

8

9

10

1 is Not ready at all, 10 is Completely ready
Is there anything we should know about your comfort level with guided practices, visualization, or talking about personal topics?
Practical Considerations
Time Zone
General availability (check all that apply):
Preferred session format:
Do you have any budget considerations you’d like us to keep in mind when matching you with a coach or practitioner? (For example, preferred fee range or other notes.)
Is there anything about your current health you’d like us to be aware of when matching you?
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.
Anything else you’d like us to know before we match you?
Agreement about Scope
Health coaching and guided imagery are educational and supportive services and are not medical care, psychotherapy, or a substitute for treatment from a licensed healthcare professional. Coaches and practitioners do not diagnose, treat, or prescribe. If you have medical or mental health concerns, please consult your licensed provider. By proceeding, you acknowledge that you understand the scope of these services.
Information you share in this form will be used to help match you with an appropriate provider or resource. NeuroTransform may share your information with selected coaches or practitioners for referral and coordination purposes and may contact you by email regarding your referral or related services. Your information will not be shared for other purposes except with your permission or if required by law.
Required
Should be Empty:

Coaching & Transformative Imagery Matching Questionnaire

Contact Details

Goals and Practitioner Preferences

Readiness and Comfort

Practical Considerations

Agreement about Scope