step
X
of
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Have you had any previous experience with life coaching or similar services before?
Yes
No
If yes, can you give a brief description of your experience?
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What type of service are you looking for?
Blend of coaching and mentoring,
Pure Coaching
No Preference
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What areas of your life would you like to focus your sessions on?
Check all that apply
Parental Guilt
Screen Addiction
Confidence
Work & Career
Finding Purpose
Emotional Wellbeing
Parent-Child Connection
Stress & Overwhelm
Family Dynamics
Other (Please specify)
Other
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Which of the following challenges and obstacles apply to you?
Check all that apply
Perfectionism
Work-Life Balance
Lack of Confidence
Screen Addiction
(yourself or your children)
Disconnected Family
Guilt
Other (Please specify)
Other
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What coaching format would you prefer?
Please select at least one
(required)
Zoom (Video)
Zoom (Audio Only)
Phone Call
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Do you have any disability or are you neurodivergent?
Yes
No
If yes, can you give a brief description of your disability or ways I can help accommodate your condition.
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During your sessions, would you be interested in any of the following extra tools?
Check all that apply
Psychology tools and exercises
Psychology theory (to understand your brain better)
Breathing exercises
Visualisation exercises
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Are there times that would be more suitable for your sessions?
Leave blank if you have no preference
Morning
Daytime
Evening
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
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Please give a short description of how you would like to feel or what you would like to have achieved by the end of our sessions together.
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How should I contact you?
First Name
(required)
Last Name
(required)
Age
Select one...
18-25
26-35
36-45
46-55
56+
Occupation
Gender
Please select one
Woman
Man
Non-Binary
Transgender Woman
Transgender Man
A gender/I don’t identify with any gender
Prefer not to state
Gender not listed
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What are you contact details?
Email
(required)
Phone Number (optional)
How should I contact you?
Email
Phone
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Great, that's all I need to know! Do you have any other information you would like me to know? If not, please press submit and I will be in touch in the next 48 hours.
Other information
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Thank you! You will receive an email confirmation shortly.
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