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NEW COACHING CLIENT ASSESSMENT
This form will take only 1 minute and is designed to help you narrow down your focus and set a clear goal and it'll help me to tailor the session for you. It can be also used to help you track progress and stay on track, or change course.
All information will be kept confidentially.
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Email
*
Your email
Name
Your answer
Telephone number
Your answer
What are the main topics you'd like to focus on?
(optional)
More Resilience (in the face of stress)
More Self-Acceptance (in the face of guilt and shame)
More Peace and Positivity (in the face of frustration)
More Presence of Clarity of Mind (in the face of confusion)
More Ease of Body (in the face of physical pain)
More Confidence (in the face of anxiety)
More Focus (in the face of procrastination and distraction)
More Motivation and Inspiration (in the face of depression)
Better Sleep, More Energy (in the face of insomnia and tiredness)
Other:
Could you summarise your main goal in one sentence?
(Eg. I'd like to become more calm and learn how to deal with my anxiety in a useful way.)
*
Your answer
QUICK HEALTH CHECK.
Roughly, in the last two weeks, how are you?
Stress levels
I roll with things calmly
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I'm SO stressed!
Clear selection
Anxiety levels
Confident in my ability to manage
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Very anxious most of the time
Clear selection
Anger levels
I deal with things calmly and assertively
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Aggressive or holding bitter resentment regularly
Clear selection
Sadness levels
Mostly happy. Sadness passes easily
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I'm stuck in feeling sad, depressed or hopeless
Clear selection
Overwhelm and Burnout levels
Coping well with the problems of life
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Coping poorly, feeling very overwhelmed!
Clear selection
Confusion / Stuckness Levels
I have a clear mind and can plan ahead well
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My mind is confused and I feel stuck
Clear selection
Procrastination levels
Achieving what I want
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Constant procrastination and avoidance
Clear selection
Physical pain/ sickness levels
Healthy body, relatively pain free
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Severe daily aches, pains and physical problems
Clear selection
Do you feel you have any conditions,
(phobias, emotional or physical traumas, triggers etc) or concerns
that may be helpful to tell me about?
If not, leave blank
Your answer
Emergency Contact
(Just in Case - Name, number, relationship) Eg. Sally Morbey, 0745885588, Mum. Or doctor's surgery name/address
*
Your answer
SIGN UP: MAKE A COMMITMENT
The satisfaction in my work comes from helping people to achieve their main goal. This only works if you do - If you are willing to practice, which is why I ask people to, literally , sign up to the following:
Check all of these if you agree to:
*
Turn up to all the sessions, or cancel more than 48 hrs in advance
Make time to practice the agreed practices after the session
Tell the coach if you are having difficulties, and ask questions - to be engaged in your learning.
Look after yourself throughout and after the session - tuning into your capacity and needs.
Read the terms and conditions
https://docs.google.com/document/d/e/2PACX-1vQOjxU7_MWGgnWZ28jWZJRTxn9Dv3SY9tPU9Mb7YoidAF0Xw09Ifj4hSsnkfDaTzZdIa7OTVh40q9j4/pub
Required
How much will you be pay (and by bank or PayPal)
? (Eg, "Paid £xx for coaching session, by PayPal") See payment info here:
https://www.positively-mindful.com/payment.html
and fee info here:
https://www.positively-mindful.com/11.html
Your answer
A copy of your responses will be emailed to the address you provided.
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