Coaching with Emile Steenveld

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***Read before you apply**

Filling out this application will put you into a waitlist to work with me. All submissions are 100% confidential.

If we work together, you will be challenged to both receive the results you desire all while being challenged to question everything you know about yourself, so you can let go of all your limiting beliefs, get present, unravel your ideas, and move into a life state that I call FLOW.

If you really want to work with me, this is your space to let me know why.

The best coach-client matches are the ones who connect on the human-to-human level, so share your personality. I want to KNOW you.

**If you are approved, my team will get in touch with you within 48 hours to schedule a discovery Zoom meeting with me to dive deeper. **

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Let's get started with the basics. What's your full name?* This field is required.

First Name

Last Name

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Why is NOW the time that makes sense for you to reach out to me?* This field is required.

This question is important, so please answer truthfully.

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What is ONE thing you want to change in your life in the next three months? What do you feel is hindering you the most from making this change?* This field is required.

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List up to ten things you would love to have in your life or 'more' of, in your life.* This field is required.

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In what area(s) of life do you experience the most stress? What creates that stress? (Be specific)* This field is required.

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On a scale of 1 to 10, how would you rate your current stress level?* This field is required.

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Low

High

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What is missing in your life today that you deeply desire?* This field is required.

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Are you consciously aware of any adverse events that happened during your childhood? (Bulling, Loss of parent/loved one, Natural Disasters, Physical Abuse, Sexual Abuse or Emotional Abuse etc).* This field is required.

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Do you have any addictions? Drugs, medication, sex, gambling, coffee, food. In other words, what do you lack self-control with that is detrimental to your health?* This field is required.

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Are you taking any prescription medication? If yes, Please list below what they are and why you take them* This field is required.Your medical history is confidential. However, we must take into account every factor that could influence your coaching sessions.

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Have you worked with a coach before or a similar one-on-one adult relationship? (e.g. coach, mentor, teacher, and therapist)? If so, what worked well for you and what did not work in the relationship(s)?* This field is required.

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What are 3-5 words that describe you?* This field is required.

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What is your email address?* This field is required.

example@example.com

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Where are you based at the moment and in what time zone are you?

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What is your phone number?* This field is required.

Country Code

Area Code

Phone Number

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What's your Instagram handle, if you have one?* This field is required.

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Where would you like to see yourself when this program is over? What do you think it will take to get there?* This field is required.

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What are the games you play against yourself that sabotage your success?* This field is required.e.g., I beat myself up for the mistakes I made, and this makes me sad.

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Which topic would you love to focus on during your first coaching session and why? (If you do not know its okay, just type I don't know yet)* This field is required.