Baseline Survey

Baseline Survey

This is the next step on your path. Please be as honest and open as possible, and remember that all information you share will be kept confidential. This will be valuable information to reflect on as you make progress.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
How did you hear about me?

ReferralWe met in personCoaching DirectoryGoogle SearchInstagramFacebookYouTubePrint AdOther
Date*

MonthDayYear
Date
Gender

MaleFemaleNon-binaryOther
Age
Relationship Status
Occupation
What has your self-discovery journey looked like up to now? (check all that apply)

CoachingTherapy (Talk, Family, Group, Somatic, etc.)Self-Help Media (Books, Podcasts, etc)Retreats (Solo, Group, etc.)Other
Share anything you would like about your history that feels relevant
Rate your level of satisfaction in the following areas:
Physical Health

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1 is Worst, 10 is Best
Mental Health

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1 is Worst, 10 is Best
Emotional Expression

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1 is Worst, 10 is Best
Intimate Relationship(s)

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1 is Worst, 10 is Best
Spirituality

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1 is Worst, 10 is Best
Career

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1 is Worst, 10 is Best
Leisure

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1 is Worst, 10 is Best
What are your top 3...
Goals Goal 1 Goal 2 Goal 3
Obstacles Obstacle 1 Obstacle 2 Obstacle 3
Strengths Strength 1 Strength 2 Strength 3
Weaknesses Weakness 1 Weakness 2 Weakness 3
Coping Strategies Coping Strategy 1 Coping Strategy 2 Coping Strategy 3
How ready and committed are you to making changes in your life to achieve your goals?

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1 is Not at all, 10 is Extremely
In a few words, what is your motivation to achieve these changes and goals?
Free Space: Letter to future/past self, other important information, anything you want to get off your chest - whatever you would like.
Please verify that you are human*
Should be Empty:

Baseline Survey

Rate your level of satisfaction in the following areas:

What are your top 3...