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New Client Questionnaire
We are so excited to learn more about you and be here to support you every step of the way. Please fill out this questionnaire with as much detail as possible so we know how to best support you based on your current lifestyle and needs. The more information you provide, the better! We at Haley Bretl Coaching value diversity, equity and inclusion and would like to know and celebrate the diversity of our community. If you have any questions, please email Haley at
haley@haleybretl.com
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Email
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Your email
First/Last Name
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Your answer
Phone Number
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Your answer
Address, St. City & Zip
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Your answer
Please tell us what time zone you're in.
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Your answer
Tell us about yourself (we want to know about YOU!)
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Your answer
What's your profession?
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Your answer
How much do you work in an average week?
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Your answer
Describe your current lifestyle. Please include your day to day, typical eating habits, energy levels, workout/movement routines.
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Your answer
Age
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Your answer
Height (nutrition consults only)
Your answer
Weight(nutrition consults only)
Your answer
How you feel now
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Your answer
How you want to feel
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Your answer
Goal Weight (nutrition consults only)
Your answer
Purposeful Activity Level (Workouts)
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1-3 hours weekly
3-5 hours weekly
5-7 hours weekly
General Activity Level
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Sit mostly throughout the day (desk work)
Up/Down/ Standing
Lots of movement, rarely sit
Do you currently have an idea on where you'd like to start in the coaching process? Please explain in detail what you are currently doing.
Your answer
What is your vision for the future? What would be a dream come true?
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Your answer
What are your top 3 goals you'd like to accomplish in the next 6 months?
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Your answer
Goal #1: Write description and priority
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Your answer
Goal #2: Write description and priority
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Your answer
Goal #3: Write description and priority
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Your answer
Have you tried anything in the past to change or create new habits, goals/lifestyle? If yes please explain.
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Your answer
Which of those things worked for you and why?
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Your answer
Which of those things didn't work for you well and why not?
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Your answer
If you were to consider maybe making more changes to your lifestyle (mental, emotional, physical, medical, social, financial, professional, spiritual, environmental, overall life joy & satisfaction) what might those be?
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Your answer
Until now what has blocked you or held you back from changing those things?
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Your answer
Right now how much support do you have around making lifestyle changes?
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Just me
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All the support I need!
Have you been diagnosed (past or present) with any specific medical conditions (illness/injuries)?
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Yes
No
Right now do you have any specific health concerns
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Yes
No
Right now are you taking any medications (scripts or OTC)?
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Yes
No
How do you feel about your overall health right now?
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Feeling stuck
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It's all good
Please elaborate on your score above
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Your answer
How are you spending you time? (think working, chores, taking care of others, volunteering, traveling/commuting, school/school work) - do your best and estimate the amount of hours in a week spent on these
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Your answer
How do you feel about your schedule, time-use and busy-ness?
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My life is panicked and insane
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My life is calm/relaxed
Given all the demands in your life, what is your typical stress level on an average day?
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No stress
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Extreme Stress
On average how many hours of sleep do you get per night?
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Your answer
How do you normally cope with your stress?
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Your answer
How READY are you to change your habits/behaviors?
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Not at all
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Completely
How WILLING are you to change your habits/behaviors?
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Not at all
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Completely
How ABLE are you to change your habits/behaviors?
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Not at all
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9
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Completely
What is GOOD about NOT changing? What is working for you with the status quo? What are the benefits of staying the same?
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Your answer
What would be BAD about changing? If you changed, what might you have to give up or lose? How would your regular routine be disrupted?
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Your answer
What might be GOOD about changing? If you changed, how would that be helpful or beneficial? What new opportunities or possibilities could open up?
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Your answer
What might be BAD about NOT changing? If you didn’t change, what bad things could happen? If you keep going the way you’re going, what might things look like in the future (say, 3 years from now)?
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Your answer
What do you think you need most from your coach? Please be specific in describing what your ideal relationship and support system looks and feels like.
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Your answer
What are you prepared to do to work towards your goals?
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Your answer
What do you feel you most urgently need with help with right now?
Your answer
Anything else you think would be beneficial for Haley to know prior to your first 1:1 call?
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Your answer
I am 100% ready to invest in myself!
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Yes
No
Maybe
A copy of your responses will be emailed to the address you provided.
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