Name
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First Name
Last Name
Preferred Name
Pronouns
Phone Number
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Country
(###)
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Email
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Mailing Address
I won't send you junk, or share this with anyone. Your address is kept confidential.
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
What timezone are you in?
Birthdate
MM
DD
YYYY
Please provide a name, phone number, and email for an emergency contact.
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What [if any] mental health or other coaching support are you currently receiving?
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What [if any] holistic/healing support are you currently receiving?
For example: acupuncture, reiki, massage, energy work
Name three specific things you're hoping to get from coaching.
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What is the biggest challenge to having/accomplishing these things?
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I will know I’ve reached my coaching goal when I... (feel like this…act like this…believe this…)
If you could wave a magic wand and manifest one thing, what would it be?
What are a few patterns or tendencies you're outgrowing? What do you want instead?
Are you going through any major transitions or changes in your life right now? If yes, please add some detail.
What are your big, seemingly impossible dreams? If you knew you’d succeed, what would you pursue?
Which aspects of your life are most energizing and joyful?
What are you longing for these days?
Which aspects of your life are most frustrating or draining?
Name a few things you did as a child that you loved and did well.
Describe a time when you were working or playing and having so much fun that you lost track of time.
How do you tend to numb or distract yourself?
Examples: social media, alcohol, drugs, buying/spending, food, sex, television, gaming
Have you ever worked with a coach before? If so, what were your key takeaways from that experience? What [if any] were the gaps from your previous coaching experience that you’d like to address in our sessions?
How did you find out about my services?
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Our coaching sessions will happen over Zoom, with video enabled. Please confirm if this works for you, or if you prefer that your coaching sessions be conducted over the phone.
I consent to using Zoom with video enabled for our coaching calls.
I would prefer to do our coaching sessions over the phone.
Tell me about how you prefer to communicate with me.
I provide light support between sessions (Monday through Friday, 9am-5pm PST), via email or WhatsApp. I want to know which mode of communication works best for you.
Is there anything else you want me to know?
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Do you want to be added to my newsletter to stay up-to-date on coaching offerings, in person gatherings, writing, and more?
