Client Application - Wellness In Heels

*** Please read and fill in ***

In order to coach you as effectively as possible, it is important for me to understand who you are, what you value and how you approach your life.

Please set aside some time to thoroughly – and honestly – answer the questions below.

Name*
First Last
Address*
Mailing Address Address Line 2 City State / Province Zip / Postal Cod Country
Cellphone (iPhone or Android)*
Primary Email*
Significant Other*
Children*
BIRTHDAY (Month / Date)*
Where did you grow up?*
Tell me about your education*
Tell me about your health/wellness as it stands right now*
What would you like it to look like in the future?*
What’s standing in the way of that happening?*
What’s the biggest change you’d like to make to your health/wellness right now?*
What does that change look like to you?*
If there was one thing you’d like to accomplish in the next 90 days that would make you feel absolutely fabulous, what would it be?*
What’s keeping you from accomplishing that goal?*
How do you tend to sabotage yourself?*
If I see you getting in your own way, do I have permission to call you out on it?*
- Yes
- No
If yes, how would you like me to address it?*
If no, why not?*
Are you in the place emotionally and financially to move forward with coaching?*
- Yes
- No
Will you commit to a three-month contract?*
- Yes
- No
Do you have any hesitations about getting started?*
What questions do you have for me?*
How did you hear about us?*
Phone
This field is for validation purposes and should be left unchanged.