WELLNESS & MINDSET COACHING APPLICATION
Thank you so much for your interest in working together. This short form will allow me to ensure we are aligned before we get connected. Tell me a little about yourself, your goals and who you're looking to become.
TELL ME ABOUT YOURSELF:
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Instagram Handle
*
How did you hear about me or this work?
*
What type of coaching are you interested in?
*
Wellness/Lifestyle
Mindset
Both
Have you worked with a coach, therapist, or practitioner before?
*
Yes
No
WHERE ARE YOU RIGHT NOW?
What's drawing you to this work right now?
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What currently feels the most challenging or out of alignment in your life?
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If we worked together successfully, what would you most want to be different about your life 3–6 months from now?
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Why do you feel now is the right time to receive support?
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WHAT DO YOU WANT SUPPORT WITH
Which areas would you most like support with? (Select all that apply)
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Minset & thought patterns
Confidence & self-trust
Rewriting Limiting Beliefs / self-sabotage
Discipline & consistency
Stress management & emotional regulation
Routines & daily structure
Habit building
Time management & prioritization
Goal setting & accountability
Fitness & physical activity
Nutrition & overall wellness
Creating a healthier, more balanced lifestyle
Other
MINDSET & LIFESTYLE
What patterns, habits, or beliefs do you feel are currently keeping you stuck?
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Where do you feel you struggle most with consistency or following through on the things you know you want for yourself?
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What does your current day-to-day routine look like? (Think work/school, sleep, responsibilities, movement, meals, downtime, etc).
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HEALTH & WELLNESS
On average how many times per week do you go to the gym or exercise?
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1-2
2-3
3-4
5+
None of the above
How would you describe your current diet? (Balanced, High-protein, Plant-based, Fast food often, etc)
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Do you have any food allergies or intolerances?
*
Are you currently taking any medications or supplements? List them.
*
COACHING FIT
If we're a good fit, are you ready to invest time, energy, and financial resources into yourself to achieve the transformation you're looking for?
*
Yes
No
Anything else you'd like me to know before we get connected?
*
Submit
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