Ready to face your fears, break through limiting beliefs and stop self-sabotage? Learn more about how you can work with me now 💜

First Name

E-mail

Have you ever worked with a life/mindset coach before?

Yes

No

Preferred coaching/learning style:

1:1 Private Coaching (phone calls included)

Self-paced (group coaching call included)

Length of coaching:

I really just need help with overcoming one obstacle and need guidance but I can apply it on my own

I'm interested in doing inner work, applying what I've learned, and working on a long-term basis for continued support and accountability

Timeframe to hire someone to help you break free and start working towards your goal:

Just looking with no definite date

Now

1-3 months

4-6 months

When something goes wrong, who do you naturally blame?

Self

Other person

God/Universe

Nobody

When something is hard, I:

Give up

Ask for help

Look for solutions

Take a break and try again later

Burn myself out until I figure it out

What is usually the reason you do not accomplish your goal?

Lack the skills

Not consistent

Talk self out of it

Do not have a clear plan to accomplish it (I know what I want but not how to get it)

Easily discouraged by comparing self to others

Easily discouraged by the negative things other people say

Can't work out

Don't know types of food to eat

How much weight would you like to lose?

0-25lbs

26-50lbs

51-75lbs

76-100lbs

100+lbs

How would you feel if you didn’t meet goal? (Refer to last question about something you want to accomplish in 30 days).

It wasn't meant to be

Better luck next time

Will find a way

Devastated

Have you been diagnosed with anxiety, clinical depression, ADHD or any other condition?

Yes

No

If you responded “yes” to the previous question, how are you managing? If you answered “no”, please skip this question.

No longer struggle with it

Holistic health

Medication

Trying to manage the best way I can but it's a struggle

Are you currently seeing a counselor, therapist, psychologist or other mental health professional?

Yes

No

As a coach, do you understand that I cannot diagnose, treat or provide medical advice?

Yes

No

Oh yess!!! Let's do this! Complete the following intake form and then book a time to schedule your 90-minute kickoff call. The cost of the call is deducted from the coaching package.