New Client Application
Please fill out the information below. By filling out this application, you are not required to move forward with coaching, but it also does not guarantee your coaching spot. I have limited coaching spots available. If I do not currently have availability, you will be added to my wait list & contacted once spots become available.
Sign in to Google to save your progress. Learn more
Email *
Name *
Age *
Occupation
What are your health related goals? (Weight loss, improve overall health, reduce body fat, build muscle, medication cessation, improve mental/physical health, learn to honor and respect your body, etc.) *
What are your life goals? (Think short & long term. This question can relate to career, relationships, travel, anything! I want you to really use your imagination on this one. Nothing is off limits!) *
I want you to take a minute and think about the best version of yourself. What does that person feel like? How does that version of you think and act? What is standing between you in this moment and the version of yourself you wish to actualize? What would you say are your biggest struggles or obstacles right now? What is holding you back from achieving your goals? Be as specific as possible. *
Do you feel that the goals you have set for yourself are within your reach? *
How would you rate your self-efficacy? (Self-efficacy is your personal belief in your ability to be successful at a given task.) *
My self-efficacy needs some work. Sometimes I doubt my own abilities and lack self-confidence.
I have strong self-efficacy. I can conquer anything thrown my way!
Have you ever struggled with an eating disorder or any other mental health conditions? (Depression, anxiety, body dysmorphia, etc.) Please note that I am not a psychologist or therapist of any sort. I can only speak from my own personal experiences with these issues. *
Do you feel that your mental health is a priority to you? *
Do you feel that your mental health is something you'd like to improve or expand on? *
Are you willing to make your overall health (physical, mental, emotional, spiritual) a priority and invest the time & energy required to see improvements? *
Would you consider yourself someone that thrives on instant gratification? Do you lose interest or motivation when things aren't happening as quickly as you'd like them to? *
Do you feel you have achieved your highest potential in all aspects of life? If not, which areas do you feel could really use the most improvement? *
Have you worked with an online coach before? *
Why are you interested in working with me specifically? What sparked your interest in my coaching? *
What do you hope to achieve from working with me? *
I am open to and respectful of all religious and spiritual beliefs and ideologies. My ideas are never intended to conflict with or contradict your own personal beliefs. My coaching does include information about chakras, astrology, and other 'metaphysical' teaching tools that I will implement where I see fit as a way to help you better understand your mind, body, spirit, and overall potential. Is this something you would be open to learning about and incorporating into your coaching? (If not, I am 100% okay with that. I want to make sure that I do not overstep any spiritual or religious boundaries.) *
How ready are you to take this next step in redefining your mind, body, and spirit? *
Very Hesitant.
I'm ready to go!
Any other questions?
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms