life and Wellness services

Name *

First Name

Last Name

Date of birth

MM

DD

YYYY

Phone Number *

Country

(###)

###

####

Which areas of your life are you seeking support in? *

(Select all that apply)

Career

Finances

Health

Family and Friends

Romance

Personal Growth

Fun and Recreation

Physical Environment

Spirituality

Are you currently using any other support services (e.g., mental health, therapy)? *

Yes

No

I am looking for guidance and strategies to achieve my goals through coaching rather than therapy. *

True

False

Would you prefer to receive support online or in-person *

(Select one)

On-line

In-Person

Which factors do you believe might be preventing you from achieving your goals? *

(Select all that apply)

Lack of clear vision

Procrastination

Fear of failure

Lack of resources (time, money, tools)

Poor time management.

Inconsistent effort

Distractions

Negative mindset

Other