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The Science & Soul of Resilient Living
Application for 1:1 Coaching Program
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Email *
Phone number *
Please share your first and last name and the name you prefer to be called. *
Please share your pronouns (e.g., She, He, Ze, They, Other, etc.) *
How did you learn about this program (please select all that apply)? *
Required
What is your employment status (e.g, full- or part-time, unemployed, retired, student, etc.)?If applicable, please descibe your occupation/discipline, the types of activities/tasks your professional life involves, and how long you have been doing this kind of work. *
Please share any information about your background, identity (e.g., race, ethnicity, gender, sexual orientation, relationship identity/status, spirituality/religious background, parenting) and/or values that you think may be important for me to know. *
What is the primary reason you are interested in this program? For example, was there something specific, such as a particular event, stressor, or life transition that prompted you to consider it? *
Please check off any of the following that are currently a challenge in your life. *
Required
Please describe your physical health and well-being. This could include sleep quality and quantity, exercise, nutrition, water intake, substance use (e.g., caffeine, tobacco, recreational drugs), health conditions or symptoms, etc. In what ways do you feel balanced and fulfilled in this area of your life, and in what ways do you see an opportunity for growth and change?
Please describe your emotional health and well-being. This can include emotions that are predominant in your life (e.g., worry, regret, guilt, sadness, joy, gratitude), specific mental health symptoms or conditions (e.g., anxiety, depression, fatigue, concentration), and/or variables affecting your emotional health and well-being (e.g., stress, adverse life experiences, etc). In what ways do you feel balanced and fulfilled in this area of your life, and in what ways do you see an opportunity for growth and change? *
Please describe your relationships with family, friends, community, and romantically. In what ways do you feel balanced and fulfilled in this area of your life, and in what ways do you see an opportunity for growth and change? Please feel free to answer this question separately for certain key relationships or types of relationships in your life. *
Please describe your relationship to your body. This could include aspects like the value and importance you place on how your body looks, how satisfied you feel with certain physical characteristics, emotions and thoughts you experience related to your body, and how you treat your body. In what ways do you feel balanced and fulfilled in this area of your life, and in what ways do you see an opportunity for growth and change? *
Please describe your professional/vocational quality of life. In what ways do you feel balanced and fulfilled in this area of your life, and in what ways do you see an opportunity for growth and change?   *
Please describe your sexual health and well-being. This could include factors like how satisfied you are with your sex life, any difficulties you experience with arousal, desire, orgasm, and/or pain, as well as your sense of self as a sexual being. In what ways do you feel balanced and fulfilled in this area of your life, and in what ways do you see an opportunity for growth and change?   *
If applicable, please describe examples of fulfillment and desire for change in other areas of your life and/or aspects of your identity. This could involve domains like parenting, volunteer or advocacy/activism work, connection to community, etc.
What do you like to do for fun or enjoyment? Do you prefer your enjoyment alone, with others, or both? *
How do you tend to manage and cope with stress? *
Do you currently have any spiritual practices? If so, what do they look like and what are their impact in your life? If not, please describe any you have tried in the past and what did and didn't resonate. *
Are you aware of anything in your life that gives you a sense of meaning, purpose, and fulfillment? If so, please describe. If not, any thoughts about what has interfered with your connection to meaning, purpose and fulfillment? *
In what ways do you feel as though your life has been both positively and negatively affected by familial, cultural, and societal messages about who you are and who you should be? *
To what extent does the way you live your life match your innermost desires, needs, dreams, and values? (0 = not at all; 10 = extremely well) *
not at all
extremely well
Are you aware of any thoughts patterns, habits, or behaviors that interfere with your quality of life? *
What are the top 1-3 concerns would you most like to address in this program? *
How open are you practicing science-backed tools and strategies both from psychology and complementary and alternative medicine (e.g., meditation, yoga, Ayurveda, etc.)? (0 = not at all open; 10 = very open)
not at all open
very open
Clear selection
How willing are you to practice tools, strategies, and assignments outside of 1:1 sessions? *
not willing
very willing
Please describe any barriers that you think could interfere with your participation in this program and how you might address them when/if they arise. *
Please share any additional information about yourself or your desire to participate in this program that you feel is important for us to know. *
How willing are you to complete a final feedback survey regarding your experience in this program? (0 = not at all; 10 = very willing) *
not at all
very
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