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
Email address *
Date of Your Eventbrite Class if applicable
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Which of the following are you most interested in? Select all that apply. *
Required
Of those items you selected above, indicate in rank order the three that have the highest priority for you. *
Your answer
Which of these psychological states interfere with your quality of life either daily or frequently? Check all that apply. *
Required
From those you indicated above, which one has the greatest negative impact on your quality of life? *
Your answer
What activities are you doing now to manage your mental and physical health at least once per week? Choose all that apply. *
Required
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? *
Full Name *
Your answer
Cell phone (What’sApp Cell preferred) *
Your answer
Thank you. Please add anything else you feel is relevant.
Your answer
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