Coach Neshama
step into your body...step into your life
Welcome Back to Coaching
I'm so happy that you have chosen to return to coaching after taking this break. To help us both get back on track, please complete this short form. If you have questions, please phone, text or email me. I look forward to sharing your healing journey with you again.
Name
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First Name
Last Name
Email
*
example@example.com
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell phone
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-
Area Code
Phone Number
OK to text?
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Yes
No
Date
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-
Month
-
Day
Year
Date
What has been going well in your life since we last met?
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What have been your biggest challenges since we last met?
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Are you comfortable with your weight and how/what you are eating? Please explain.
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How stressed are you?
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1
2
3
4
5
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7
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9
10
1=not stressed; 10 = extremely stressed
What is stressing you out right now?
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What, if anything, do you do to manage stress (check all that apply)?
Prayer
Meditation
Visualization
Music
Yoga,
Qi Gong
Journaling
Breath work
Exercise
Chanting
EFT (tapping)
Time with supportive family, friends, mentor, therapist, coach
Other
How would you categorize your digestion?
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1
2
3
4
5
6
7
8
9
10
Great
Terrible
1 is Great, 10 is Terrible
Comments about digestion:
What goals would you like to achieve in coaching this time (outcomes)?
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How motivated do you feel right now to commit to coaching and your wellness goals? Including: showing up for sessions; doing "homework" between appointments; making time each day for your healing journey?
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1
2
3
4
5
6
7
8
9
10
Very motivated
Not at all motivated
1 is Very motivated, 10 is Not at all motivated
Is there anything else that is important to share at this time?
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