The Conscious Life & Wellness Coaching Application

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First + Last Name *

Email *

Best number to reach you at? *

How did you hear about us? *

What are the biggest changes you want to make in your life in the next 3 months? *

Why is it important for you to achieve these goals? *

What are the biggest changes you want to make in your life over the next 3 years, Where do you feel you will be 3 years from now if you do not make these changes? *

What are the current challenges you face that keep you from progressing toward the change you desire? *

What major transitions have you had in the past two years?(Example:Enteringorapproachingadifferentage,anewordifferentrelationship,jobrole,residence,achangeinchildren’sages/stages,etc.) *

Have you participated in a program in the past that has helped you make achieve a goal or outcome? If so what worked, what did not? *

What types of approaches discourage you or take away motivation? *

What do you expect to achieve as a result of hiring me as your coach? *

How many hours / week are you willing to commit to acheive the outcome you desire? *

1-2

2-3

3-5

As much as needed

If you are accepted, how soon are you looking to start? *If you are not ready, please wait to submit until you are ready to commit. *

I realize I am booking a real time with Kerrie or one of here team members, by showing up to the time I select. *

Yes, I agree.

I understand that cancels, reschedules or no-shows without a 2 hour notice will not be rescheduled. *

Yes, I understand.

Submit

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