Getting To Know You
So Jacquie can get to know you better,  please take your time filling the following information. The more information you give the better understanding Jacquie will have of you. 

All information given is private and confidential. 

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Email *
Name (how you prefer to be addressed):
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Contact Number  *
Gender identification/pronouns:
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The best way to contact you: 

Phone, Zoom, E-Mail, Text, What’s App, FB Messenger

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How did you hear about me?
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When and what time of the day do you feel the most energised and have the greatest ability to focus?

Mondays,Tuesdays,Wednesdays,Thursdays,Fridays,

Saturday Morning 


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Get Know You
Finding out about you 
What is your current state of health? 
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Are you on any type of medication, if yes what:
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Do you suffer from epilepsy? Incase we do any hypnotherapy 
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Have you seen or are you currently seeing a therapist? How did it help you in the past , How is it it helping you now? 
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Do you experience any negative emotions Guilt/ Anger? 
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Are there any particular negative memories associated with the issue? 
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1. How much exposure have you had to Law of Attraction (LOA)?
none so far            
new to LOA                       
some understanding                   
really get it

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2. How much exposure have you had to the idea of Allowing True Love of yourself or others?
none so far            
new to Allowing               
some understanding                   
really get it

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3. Are there any cultural/religious/spiritual practices Jacquie needs to be aware of in order to fully honour & respect your culture/faith/commitments?        

Yes__  No__

If “Yes”, what are they?
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4. Which option below is a focus for you: 

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5. What things inspire happiness for you and what hobbies/passions/interests do you LOVE?
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6. What areas of your life already feel successful and positive for you? 
( family experiences, friendships, skills, abilities & talents, adventures & travel experiences, great interactions with pets, etc. all count!): 
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7. Are you willing to give your time, be authentic and allow some self-love during our time together? 

Yes

No_


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8 What would your life be like if you had what you wanted ? ( A fabulous relationship, Clarity over confusion, calm, quite head ) 

What would that be worth to you? 

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9. Why do you feel coaching will benefit you right now & what results would you like to experience?

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10. Are you willing to learn new things and approach this experience with an attitude of openness and willingness? 
Yes 
No

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Fabulous
Thank you for answering these questions, Jacquie will be in contact shortly to arrange an appointment. 
A copy of your responses will be emailed to the address you provided.
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