New Client Questionnaire
We are so excited to learn more about you and be here to support you every step of the way. Please fill out this questionnaire with as much detail as possible so we know how to best support you based on your current lifestyle and needs. The more information you provide, the better! We at Haley Bretl Coaching value diversity, equity and inclusion and would like to know and celebrate the diversity of our community. If you have any questions, please email Haley at haley@haleybretl.com
Email *
First/Last Name *
Phone Number *
Address, St. City & Zip *
Please tell us what time zone you're in. *
Tell us about yourself (we want to know about YOU!) *
What's your profession? *
How much do you work in an average week? *
Describe your current lifestyle. Please include your day to day, typical eating habits, energy levels, workout/movement routines. *
Age *
Height (nutrition consults only)
Weight(nutrition consults only)
How you feel now *
How you want to feel *
Goal Weight (nutrition consults only)
Purposeful Activity Level (Workouts) *
General Activity Level *
Do you currently have an idea on where you'd like to start in the coaching process? Please explain in detail what you are currently doing.
What is your vision for the future? What would be a dream come true? *
What are your top 3 goals you'd like to accomplish in the next 6 months? *
Goal #1: Write description and priority *
Goal #2: Write description and priority *
Goal #3: Write description and priority *
Have you tried anything in the past to change or create new habits, goals/lifestyle? If yes please explain. *
Which of those things worked for you and why? *
Which of those things didn't work for you well and why not? *
If you were to consider maybe making more changes to your lifestyle (mental, emotional, physical, medical, social, financial, professional, spiritual, environmental, overall life joy & satisfaction) what might those be? *
Until now what has blocked you or held you back from changing those things? *
Right now how much support do you have around making lifestyle changes? *
Just me
All the support I need!
Have you been diagnosed (past or present) with any specific medical conditions (illness/injuries)? *
Right now do you have any specific health concerns *
Right now are you taking any medications (scripts or OTC)? *
How do you feel about your overall health right now? *
Feeling stuck
It's all good
Please elaborate on your score above *
How are you spending you time? (think working, chores, taking care of others, volunteering, traveling/commuting, school/school work) - do your best and estimate the amount of hours in a week spent on these *
How do you feel about your schedule, time-use and busy-ness? *
My life is panicked and insane
My life is calm/relaxed
Given all the demands in your life, what is your typical stress level on an average day? *
No stress
Extreme Stress
On average how many hours of sleep do you get per night? *
How do you normally cope with your stress? *
How READY are you to change your habits/behaviors? *
Not at all
Completely
How WILLING are you to change your habits/behaviors? *
Not at all
Completely
How ABLE are you to change your habits/behaviors? *
Not at all
Completely
What is GOOD about NOT changing? What is working for you with the status quo? What are the benefits of staying the same? *
What would be BAD about changing? If you changed, what might you have to give up or lose? How would your regular routine be disrupted? *
What might be GOOD about changing? If you changed, how would that be helpful or beneficial? What new opportunities or possibilities could open up? *
What might be BAD about NOT changing? If you didn’t change, what bad things could happen? If you keep going the way you’re going, what might things look like in the future (say, 3 years from now)? *
What do you think you need most from your coach? Please be specific in describing what your ideal relationship and support system looks and feels like. *
What are you prepared to do to work towards your goals? *
What do you feel you most urgently need with help with right now?
Anything else you think would be beneficial for Haley to know prior to your first 1:1 call? *
I am 100% ready to invest in myself! *
A copy of your responses will be emailed to the address you provided.
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