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The Healing Rebel Coaching Application Form
Before I start working with anyone I need to make sure that we are the right fit, no one wants to waste time or money and not get what they are looking for
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Email
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Your email
Full Name
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Your answer
email address
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Your answer
Postal Address & Post Code
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Your answer
Mobile Number
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Your answer
Please confirm that you are happy for me to contact you via (this is for our communication during mentoring) tick all that apply
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Email
Post
Mobile (text &/or calls)
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Date of Birth
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MM
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DD
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YYYY
would you like to be added to the email list to receive weekly emails with updates of courses/workshops/podcasts/recipes/suggestions to navigate life more positively? (you can subscribe at any time)
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Yes please
No thanks
Required
What other courses/programmes/memberships are you CURRENTLY signed up to? (gym, personal trainer, weight watchers, therapist etc)
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Your answer
What other courses/programmes/coaching have you PREVIOUSLY tried? (gym, personal trainer, weight watchers, therapist etc)
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Your answer
What is it that you feel you need help with NOW that you are doing The Healing Rebel programme? (give as much detail as possible)
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Your answer
Do you have any injuries, health conditions (including ANY surgeries) that you haven't mentioned in the previous answer?
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Your answer
If you have an underlying health condition, are you seeing a doctor/specialist/anyone else about this?
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Your answer
Is your doctor currently prescribing medication? (if yes please advise)
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Your answer
What is one thing that you want to achieve in the 90 days?
Your answer
How will you know you have achieved this?
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Your answer
What has STOPPED you in the past?
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Your answer
WHY do you feel ready to do this now?
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Your answer
What support do you have around you?
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Your answer
Are you ready to ask and accept help when you need it? How have you been in the past asking and/or accepting help?
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Your answer
Tell me about a typical day? (time you get up, right through to bed time)
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Your answer
What do you currently do to relax and rest?
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Your answer
What is your current exercise/movement/activity?
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Your answer
What is your relationship with food like? (do you love food, see it as an essential part of life, have a love/hate relationship, had disrupted eating issues, not bothered etc)
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Your answer
Do you smoke?
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Yes
No
If you do smoke, how many a day?
Your answer
Do you drink alcohol?
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Yes
No
If you do drink alcohol, how often and roughly how much? (bottle of wine a night/week/weekend etc)
Your answer
What would your dream working day look like?
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Your answer
What would your dream non working day look like?
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Your answer
How good are you at sticking to a plan?
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Your answer
If you have ever worked with a coach/trainer/therapist etc before, what did you like best about working with them?
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Your answer
If you have ever worked with a coach/trainer/therapist etc before, what did you like least about working with them?
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Your answer
Is there anything else that you feel would be relevant for me to know at this time?
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Your answer
How did you hear about me?
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search engine (eg google)
flyer
word of mouth
facebook
instagram
YouTube
Other:
Send me a copy of my responses.
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