Name

Email Address

Phone

Date of Birth (YYYY/MM/DD)

How would you describe your current well-being? How would you describe your current well-being? Excellent Good Fair Needs Improvement

Have you ever worked with a coach, therapist, or advisor before? Have you ever worked with a coach, therapist, or advisor before? Yes No

Your Goals - What motivated you to seek coaching/advisory services at this moment?

Have you received any medical diagnosis that may be relevant to your current situation? Have you received any medical diagnosis that may be relevant to your current situation? Yes No Prefer not to answer

Are you currently under the care of a healthcare professional (doctor, psychologist, psychiatrist)? Are you currently under the care of a healthcare professional (doctor, psychologist, psychiatrist)? Yes No

Are you currently taking any medication, supplements, or other health-related products? Are you currently taking any medication, supplements, or other health-related products? Yes No Not Sure

How would you like to work together? How would you like to work together? One-on-one online sessions Group sessions Workshops / Programmes Not sure yet

What times are generally most convenient for you? What times are generally most convenient for you? Mornings Afternoons Evenings Weekends

Consent & Privacy Consent & Privacy I confirm that I understand this questionnaire and the advisory sessions are not a substitute for medical diagnosis or treatment.(obligatory) I agree that my personal data may be used exclusively for providing coaching/advisory services and to respond to my request.