Application for The Brainshift Private Coaching Program
Hello! This survey is to help me get to know you to determine if we are good fit for one to one coaching. Please fill out all the sections to the best of your knowledge. Thank you, Teresa Durga
Date of Your Eventbrite Class if applicable
Which of the following are you most interested in? Select all that apply.
1) Reducing anxiety and anxiety management
2) Controlled procrastination habits
3) Improved mental focus and stronger concentration
4) Improved communication in important relationships
5) Increased clarity and confidence in decision making
6) Improved general state of mind and overall happiness
7) Better night's sleep
8) Improved respiratory fitness
9) Improved skeletal-muscular fitness
10) Improved digestion
11) Addiction management
12) Deepen meditation practice
13) Strengthen vocal presence
14) Improve public speaking or ability to speak up for yourself
Of those items you selected above, indicate in rank order the three that have the highest priority for you.
Which of these psychological states interfere with your quality of life either daily or frequently? Check all that apply.
2) Feeling overwhelmed
3) Deep sadness
4) Lack of concentration
7) Irrational fear
9) Ungrounded joy
From those you indicated above, which one has the greatest negative impact on your quality of life?
What activities are you doing now to manage your mental and physical health at least once per week? Choose all that apply.
Running, swimming or biking
Working out at a gym
Yoga, Tai Chi, Ki Gong classes
Workout with a personal trainer
My age range is
Have you ever worked with a life coach or mentor before?
How ready are you now to make a full commitment of time, energy and finances to create the life you want?
I have (or will find) the time, energy and money create the change I want in my life
I have the time and energy but not the money
I have the money but am not sure how much time and energy I have to commit
Cell phone (What’sApp Cell preferred)
Thank you. Please add anything else you feel is relevant.
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