Intuitive Life Coaching with WildFlower Institute – Intake Form

So that we can provide you with the best life coaching possible, before having your initial appointment with one of our coaches, please fill out the form below. Help us to help you achieve success breakthroughs in your life by filling out this questionnaire as completely as possible.

Thanks and Blessings!

Jessalyn and the WildFlower Institute Tribe

Name: *

Date: *

Home #: *

Work #:

Cell #:

E-mail: *

Height *

Weight *

Age *

Sex *

Marital Status *

Education: *

College Degree *

Major:

Occupation: *

Favorite Hobbies: *

Do you enjoy your work? *

Are you satisfied with your income? *

Are you currently under the care of a physician? *

Do you feel stress (explain)? *

Do you exercise? *

How often? *

What type? *

What worries you most? *

How did you hear about us? *

Please rate your satisfaction with your life in the following areas (1 – worst, 5 – best) : Emotions *

Please rate your satisfaction with your life in the following areas (1 – worst, 5 – best) : Relationships *

Please rate your satisfaction with your life in the following areas (1 – worst, 5 – best) : Sexuality *

Please rate your satisfaction with your life in the following areas (1 – worst, 5 – best) : Body *

Please rate your satisfaction with your life in the following areas (1 – worst, 5 – best) : Work *

Please rate your satisfaction with your life in the following areas (1 – worst, 5 – best) : Money *

Please rate your satisfaction with your life in the following areas (1 – worst, 5 – best) : Spirituality *

What one thing do you want more of in your life right now? *

What one thing do you want less of in your life right now? *

List three things you are tolerating right now in your personal life. *

List three things you are tolerating right now in your work life. *

What’s one thing you would like to achieve but aren’t sure how to do it? *

Listed below are some typical results experienced by coaching clients. Which 3 are most important to you? (direction, focus, accountability, a new perspective, relationship success, strategies, better finances, motivation, new challenges, other-please list) *

How well do you keep your commitments when taking advice or working with someone towards your goals? (very, moderately, not too much) *

Do you have any specific goals and/or intentions for this program? *

How committed are you to making this program work for you? *

What is the most important element in deciding to use our services (select one): *

Effectiveness (your results)

Time (how fast you get results)

Service (how we respond to your needs)

Affordable (what we charge)

Appointments are available between 3-10pm (CST) Monday-Friday. Are there any particular days/times that work better for you? If so, please list the days/times that work best. *

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Intuitive Life Coaching with WildFlower Institute – Intake Form

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