Optimal Wellness Coaching Program
Please answer the following questions to help me get to know you, and to determine if the Optimal Wellness Coaching Program is right for you!

As part of the application process, there will also be a free coaching assessment session scheduled after completion of the form.
Name: *
Your answer
Phone: *
Your answer
Email: *
Your answer
Address (City/Province in which you are located) *
Your answer
Program Option Preference *
Preferred Coaching Session Delivery Method *
I am interested in Wellness Coaching because.. *
Your answer
Do you feel you are ready to make big changes and do the hard work? *
When would you be ready to start the intensive coaching process? *
Your answer
If that timeframe couldn't be accommodated, when would your next preference be (by month/year)? *
Your answer
How ready do you feel you are for change? *
Not ready at all
Couldn't be more ready
The areas of my life where I feel satisfied are:
Your answer
The areas of my life where I feel dissatisfied are:
Your answer
Some of the things that bring me joy in my life are:
Your answer
Some of the things that stress me out are:
Your answer
Some of the goals I have are:
Your answer
My biggest challenges to my wellness right now are:
Your answer
The biggest things that hold me back from living my life are:
Your answer
I am bothered by:
If I could experience optimal wellness, my life would change in the following ways: *
Your answer
My current level of wellness impacts my ability to: *
In my life I really wish I had more: *
Your answer
In my life I really wish I had less: *
Your answer
On a scale from 1-10 I would rate my current stress level as: *
Calm and Centered
Stressed and Overwhelmed
On a scale from 1-10 I would rate my current dissatisfaction with my current life as: *
Not really that dissatisfied, things are pretty good
Extremely dissatisfied
Outside of 1:1 sessions please indicate how much homework/assignments would you be able to commit to? *
Have you ever worked with a Life/Wellness Coach before? *
What would a great coach look like to you? *
Your answer
How are you best motivated? *
Your answer
I think Wellness Coaching will help me:
Your answer
Is there anything else you would like me to know about?:
Your answer
How did you find out about Optimal Wellness Coaching? *
Your answer
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