Mindfulness & Wellness Coach

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Mindfulness & Wellness Coach Client Participation Sign-Up

First Name | Last Name *

Email *

Address *

Phone number *

Work phone number *

Birth Date *

Marital Status *

Occupation *

Have you ever been treated for an emotional problem? If yes, please explain. *

Have you even been treated for: diabetes, heart disorder, or digestive problems? If so, please explain. *

Are you being treated for any illness and under medical supervision? If so, please explain. *

Have you ever had a coach before? If so, please explain. *

Have you practiced meditation or mindfulness before? If so, how often? *

What make mindfulness and wellness of interest to you? *

What do you want to accomplish through coaching? *

What are the main three goals you want to accomplish in the next 12 months? *

What are the biggest challenges you are facing right now? *

Any previous efforts to solve this problem? Any results? *

How did you hear about me? *

Medical Referral

Relative

Friend

Social Media | Google

Other

Required

Please name the person or source on how you heard about me. *

Do you have any fears or phobia? *

I am willing to be coachable and I understand that I am in control of my effort and the results perceived from such. Throughout the working relationship, the coach will engage in direct and personal conversations. The client can count on the coach to be honest and straightforward in asking questions and making requests. The client understands that the power of the coaching relationship can only be granted by the client, and the client agrees to do just that - have the coaching relationship be powerful. If the client believes the coaching is not working as desired, the client will communicate and take action to return the power to the coaching relationship.

Mindfulness Wellness Coaching does not replace licensed medical support and should be a complement to traditional medicine and not a replacement.

I understand that coaching is not a substitute to counseling, mental health care or substance abuse treatment, and that coaches are not licensed health care providers or therapists and must no provide medical advice, engage in patient diagnostics, or practice therapy.

Yes, I understand and agree with the statement above
*

Yes

Required

Name I like to be called *

Signature | Date *

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