MindBodySpirit Coaching Questionnaire
Thank you for your interest in treating yourself as a Whole Person: MindBodySpirit. Please thoroughly complete this questionnaire to help us understand how we can help you best. Make it a great day!
Email address *
Today's date *
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Name *
Your answer
Date of birth *
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Best phone *
Your answer
How did you hear about Condition for Life? *
Your answer
Tell us about yourself...as a person, not what you want to achieve, not yet! *
Your answer
Tell us about your current status, where you are and what's going on today. *
Your answer
Tell us about your preferred status, where you want to be and want to have going on tomorrow. *
Your answer
Tell us about the GAP between your current and preferred status and what keeps you from getting where you want to be. *
Your answer
What 3 words best describe how you'll feel when you get where you want to be? *
Your answer
In contrast, what 3 words best describe how you feel relative to where you are today? *
Your answer
What are your biggest sources of stress? *
Your answer
How do you measure success in any given day? *
Your answer
What 3 fear-based emotional states do you experience most often (frustration, disappointment, resentment, anxiety, overwhelm, anger, disgust, criticism, doubt, guilt, insecurity, shame, loneliness, betrayal, abandonment, sadness, depression, etc.)? *
Your answer
What 3 love-based emotional states would you like to create your preferred life from (peace, joy, contentment, fulfillment, compassion, balance, significance, worthiness, courage, confidence, respect, hope, excitement, gratitude, honor, loyalty, integrity, etc.)? *
Your answer
On a 1-5 scale (1 is low, 5 is high), rate your quality of life relative to STRESS: *
On a 1-5 scale (1 is low, 5 is high), rate your quality of life relative to MINDSET: *
On a 1-5 scale (1 is low, 5 is high), rate your quality of life relative to RELATIONSHIPS: *
On a 1-5 scale (1 is low, 5 is high), rate your quality of life relative to REST: *
On a 1-5 scale (1 is low, 5 is high), rate your quality of life relative to NOURISHMENT: *
On a 1-5 scale (1 is low, 5 is high), rate your quality of life relative to MOVEMENT: *
Do you tend to be more... *
When it comes to my needs... *
Does change feel like more of an... *
What's your relationship with failure... *
My natural approach is... *
What days/times are you available to schedule your complementary, initial session? *
Your answer
Is there anything else you’d like to share?
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A copy of your responses will be emailed to the address you provided.
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