New Client Questionnaire

Full Name *

Phone *

Email *

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Date of birth *

Each of us has our own unique way of perceiving the world and interacting with others. As your practitioner/coach, it’s important for me to get a sense of how you view the world and yourself in it.

The following questions are designed to help me get to know you better. They are intended to be contemplated and to stimulate your thinking in a way that will make our work together productive and rich. Give yourself enough time to consider the questions before you write your responses.

If you are truly coming up blank on an answer, you may simply write your thoughts about that phenomenon, or why you don't know.

What do you hope to achieve from our time together? *

Problem / Issue / Pain

Please describe the issue/circumstance we will be addressing/working on together. *

Please list all the relevant events that you think are contributing to this issue? *

What or who are you looking for to help you change this issue /circumstance? *

When did the issue/circumstance begin? *

Please tell me the names of the people who are involved, and their relationship to you, if applicable? *

What are you always apologizing for? *

What circumstances do you find yourself in repeatedly? *

What drives you crazy? *

What would your life be like if this is no longer an issue? *

Have you ever been diagnosed with a mental health condition or disorder in the past or recently? If so, please name them. *

What if any, medications, supplements, or treatments you you currently use? *

What other healing techniques and/or modalities have you used to change this problem? *

Now for the good stuff...

If time or money were not a worry and you could have your "dream" life, what would that look like, feel like, sound like? Act as if you did not have the problems in life keeping you from this. Please be as detailed as possible. Write it as if you have it now. *

What activities have joy and meaning for you? What makes you light up?? *

Do you believe in the concept of a higher power? Are you practicing a particular faith or have a philosophy/mantra you live by? What are your spiritual beliefs if any? *

What can I say to you when you are "stuck" that will bring you back to the present moment? *

What do you contribute to the world that is unique? *

Think about one or two people who really inspire you. What is inspiring about them? *

Look forward 20 years... you are attending an event and someone is giving a speech about YOU! What would you want them to say? *

Describe your essence in 3 words: *

Investing in yourself...

How willing are you, really, to let go of the issue/circumstance you described above? *

Are you willing to take consistent, actionable steps that I assign you so that you transform your life? *

Between sessions, how much time are you willing to invest in practicing the techniques you learn? *

What other healing modalities, supplements, or medications will you be using at the same time you are doing coaching sessions with me? *

What would you NOT want me to know about you? ( ;-), grin)? *

What else would you like me, as your coach, to know about you? *

If you are currently unemployed, or are receiving disability benefits or other outside financial support, briefly explain your situation: *

Phew! You did it…Great job!

I know completing this took a fair amount of energy, time, commitment, and honesty and I want to commend you for getting it done.

By doing this pre-coaching work you have taken your first steps to freedom, to recalibrating your life. Together, we are creating a powerful partnership that will give you crystal clarity about your options and a new outlook on what’s possible.

I'm here to encourage, guide, illuminate, and empower you as you take action for the wonderful new beginning you are creating.

Think about how it will feel to make decisions and move forward with well-deserved ease and freedom…

Welcome to your new life!

With peace and love,

Carolyn Miller