Diabetes Dominator Coaching Consultation Application - Diabetes, Life & Health Coaching
***IMMEDIATELY AFTER COMPLETING THIS APPLICATION, YOU MUST CLICK THE LINK TO SCHEDULE YOUR DISCOUNTED COACHING CONSULTATION***

Well done! Taking the time to fill this questionnaire out shows that you're dedicated to taking conscious, intentional action to create your own SUSTAINABLE healthy lifestyle through cultivating the life-changing daily self-love PRACTICES! Your answers will help make your session with Daniele tailored to your specific needs and goals.
#1 *
IN THE BOX BELOW, PLEASE ENTER YOUR NAME, EMAIL, & PHONE NUMBER. WITHOUT THIS INFORMATION WE MAY NOT BE ABLE TO CONTACT YOU.
#2 *
IF YOU HAVE DIABETES ONLY - IF NOT, SKIP TO QUESTION 5 AND TYPE N/A IN BOXES 2-4! What type of diabetes do you have? At what age were you diagnosed? How old are you now? If you are filling this form out for someone else, please answer the questions and state your relationship to that person.
#3 *
How many times a day do you check your blood sugar with a glucometer? Do you wear a CGM and/or an insulin pump?
#4 *
What was your last Hemoglobin A1c value and when was it taken?
#5 *
What do you generally have for breakfast, lunch, dinner, snacks? Do you have any challenges around food that you struggle with?
#6 *
How many ounces of water do you drink per day?
#7 *
What do you do for exercise? Are you satisfied with your level of physical fitness? If not, what (very specifically) are your challenges?
#8 *
Please describe your overall outlook on life (as specific as possible). In what ways would you like to improve your mental/emotional health? Your spiritual health? Your physical health?
#9 *
How many hours of sleep do you get each night?
#10 *
What is your main challenge and what is your number one goal you are aiming to reach in the next 3 months?
#11 *
How committed are you to do whatever it takes to make SUSTAINABLE, positive changes in your mind, body, spirit health habits and choices, and in your life overall? Are you willing to give yourself the gift of investing focused and compassionate time, energy, and financial resources to heal your relationship with your health? Rate your commitment using a scale from 1 - 5, where 1 = I'm completely satisfied with staying where I am currently and am not willing to invest in myself, and 5 = I'm beyond ready to commit to making real changes that support all areas of my health and wellness and am excited about investing in myself in this life-changing way.
#12 *
How did you hear about this opportunity for a discounted coaching consultation?
#13 *
Please initial here to confirm that you understand that if you qualify: 1) you will be prompted to schedule a time for your discounted coaching consultation once you submit this form and 2) if you need to reschedule your discounted coaching consult after you initially schedule it, you must contact us at Coach@diabetesdominator.com to let us know within 24 hours of your originally scheduled session. If you do not show up for your session/do not let us know you need to reschedule ahead of time, you will not be able to schedule again.
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