LET’S work together

Please fill out this required intake form with as much detail as possible. The more I know, the faster we can get started.

Name

First Name

Last Name

Pronouns / Gender

Email

Phone

Country

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Age

Date of Birth

MM

DD

YYYY

Relationship / Marital Status

Occupation

1. What changes would you like to make in your life over the next few years ?

2. What short-term goals would you like to accomplish over the next few months ? Why ?

3. What do you feel is hindering you the most from making those changes ?

4. What previous steps have you already taken to achieve your goals ? What has been the result so far and what have you learned ?

5. What do you value most in life ? Do you feel that you currently have what you value most ?

6. How would you rate your stress level on a scale from low (1) to high (10) ? What’s causing you stress ?

7. Imagine yourself at the end of your mindbody coaching experience. What is different in your life ? How have you changed ? What do you think it will take to get there ?

8. How did you hear about us ?

Anything else you want me to know before our session ?

AGREEMENT/REMINDERS:

I understand that all information I entered in this form will be considered strictly confidential.

The data gathered from this form will only be used as a basis for the type of coaching the client will need.

LET’S work together

MARIA NAUMANN