Coaching Questionnaire Step 1 of 5 20% Welcome! I can't wait to hear more about what's going on with you and what you want to achieve with coaching. Expect to take about a half an hour to complete this questionnaire. Share with me only what you're comfortable in sharing and feel free to skip any questions, if you prefer. Here's to the journey ahead! Basic InfoName* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last What are your pronouns? Email* Google DriveWe use Google to manage documents for your coaching. Will the above email work in Google? Yes No Gmail addressPlease provide a secondary gmail email address that we can share your documents to. Subscribe to NewsletterWould you like to subscribe to my newsletter for inspiration and practical wellness tips? Yes! No thank you Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Profession* Birthday MM slash DD slash YYYY Preferred scheduling for coaching sessionsWhich days and times work best for you?What are your top 3 goals?This can be in anything: wellness, career, relationship, creativity, etc.What do you feel like you do really well? What do you have dialed in?What are you struggling with most?How do you want to feel in your life? Let your imagination run wild. Concepts, images and feelings. What do you want?What made you decide to invest in coaching now?What do you hope to get out of coaching? How do you want your life to be different once you've succeeded with coaching?What are your top 3 core values?For example: authenticity, living in harmony with nature, loyalty, self-awarenessHow do you learn best? By listening By talking through something By seeing it written out I'm a visual learner. I love pictures and videos. Other How do you like to be supported? Select All Text checkins Email checkins Scheduled coaching sessions Home practices All of the above How much structure do you prefer? I like to take it as it comes. Too much structure overwhelms me. I need a lot of structure to feel confident in the process. I like a mix of structure and responding to the needs of the moment. Food & EatingDo you have any philosophies that you follow (raw, vegetarianism, vegan, paleo, etc)?What do you like to drink? Water with ice Water at room termperature Soda Wine, beer, mixed drinks Hot tea Coffee Other How many cups of pure water do you drink per day? How many meals do you eat per day including snacks?*Two or lessThreeFourFiveSix or moreWhat do you typically eat?*What are your guilty pleasures? What do you crave?*What percentage of your diet is fresh, organic whole foods?*More than 75%More than 50%, less than 75%50%More than 25%, less than 50%Less than 25%How would you rate your relationship with food? (10 being awesome, 1 being terrible)*Please enter a number from 1 to 10.Please explain why you chose that number.Have you ever had an eating disorder?* Yes No Unsure/maybe Are you a fast or slow eater?* Fast Slow In between What time do you generally eat each meal?*Do you eat your meals at the same time on most days?* Yes No Please tell me more about your answer:What needs to change in order for your food and eating habits to be AMAZING?* Work & PlayHow many hours per week do you work (including out-of-office email and texting)? How do you feel about your job (choose as many as you want, even if they’re contradictory)? I love it! It’s exhausting I hate it! I don't know what I want I’m excited about the future I’m at a really good point right now I’m working hard to get somewhere better How many times per day do you check your email? How many times per day do you check your phone? How does your work relate to your wellness?What needs to change in order for your career to be AMAZING?Sleep & energyOn a scale of 1-10 how would you rate your sleep quality? (10 being awesome, 1 being terrible)*12345678910Why did you choose that number?What time do you go to bed? What time do you fall asleep? What time do you wake up in the morning? Do you wake up in the middle of the night? How much downtime do you have each day? What do you do in your downtime? What do you do to replenish your energy? How often do you have fun? What do you do? Body & mindHow do you feel about your body?What kind of exercise do you do?Describe your routines around exercise and movement.How often, what time of day, what other activities you do around itIf you meditate, how often and for how long?Do you have a spiritual practice?How critical are you of yourself (10 being "I can't do anything right.", 1 being "I'm awesome and I love myself")?12345678910Rate your energy level on a scale of 1-10 (1 being a puddle of goo on the couch and 10 being happily active and able to sleep at night).12345678910Which of the following do you often feel?* Stressed out Overwhelmed Scattered Worried Anxious Resentful or critical Jealous Angry Lethargic Depressed Stubborn Stuck Health history & profileThe questions below help me to understand Hair: Is your hair Thick Thin Wavy Oily Dry Bones: Would you describe yourself as:* Big boned Average Thin long bones Skin: Is your skin: Red or have rashes easily Dry Oily Moist and smooth Digestion: what kind of digestive symptoms do you often experience? Belching Bloating Gas Constipation Acid reflux Diarrhea Slow digestion Stuck feeling None that I know of Elimination: How often do you go #2? 3+ times per day 2 times per day Once per day Less than once per day Is your poop: Small and dry, like pellets One formed piece Bulky Mucousy Loose and unformed As a kid, what kind of health challenges did you experience? Sore or strep throats Lots of mucous Acne Body image challenges Excess weight Underweight Difficulty concentrating or ADHD Skin issues Digestive issues What allergies or intolerances do you have?What diagnoses do you have?Ex. hypothyroidism, diabetes, depression, anxietyWhat kind of supplements do you take daily? Vitamins Herbs Hormones Prescription drugs Over-the-counter drugs Other What prescription medications do you take? What major illnesses, surgeries or accidents have you had?Therapeutic modalitiesWhat kind of therapies are you interested in? Herbs Aromatherapy Floral essences Crystal therapy Mantra therapy Color therapy It all sounds intriguing Not sure Anything else?Is there anything else that you feel is relevant to understand your current mind, body and soul?CommentsThis field is for validation purposes and should be left unchanged.
