INITIAL CLIENT SURVEY AND AGREEMENT

 

Client Survey

Please answer the following questions to the best of your ability. Include all relevant details that could help me better understand your lifestyle and assist you on your journey to feel your best.

Full Name:

Email Address:

Phone Number:

Birth Date:

Occupation:

Where do you live in the world?

How often do you travel?

Briefly describe your home/family life:

What are your top 3 reasons for choosing to work with me?

What are the top 3 things you want to work on in your life?

What are your biggest health challenges at the moment?

What inner blocks do you think are holding you back from achieving your optimal health?

What makes you feel stressed or worried?

What are your biggest strengths and weaknesses?

What do you typically procrastinate on in your life?

List your typical daily routine:

What techniques have you tried in the past that worked for you and made you feel better? What have you tried that did not work for you?

Do you have people in your life that will support your journey to your most radiant self?

If you had a magic wand, what one thing would you change immediately about your life?

How committed are you to transforming yourself to achieve optimal health?

What 3 main goals do you wish to focus on in our time working together?

How do you want to feel in the next 6 months? Describe in detail.

Have you ever worked with and had great results from a healer, coach, or medical practitioner before? Please describe your experience.

If you have worked with a coach, healer or medical practitioner before, what were the things you liked and disliked about your collaboration?

 

Client Agreement

As a Wholistic client, there are responsibilities you must respect and adhere to in order to maximize your results and ensure your journey to feel your best is not compromised. Please agree to each of the following statements of responsibility and sign your consent to adhere to these expectations.

I agree to show up on time and without distractions to our appointed monthly calls.
YESNO

I agree to give my best effort to adhere to Wholistic protocols before, during, and after the program.
YESNO

I agree to keep a positive focus on my ability to feel my best.
YESNO

I agree to take 100% responsibility for my own success.
YESNO

I agree to implement the protocols jointly decided upon during coaching calls.
YESNO

I agree be open, coachable, and ready to explore new ways of thinking or being on this journey.
YESNO

I understand there is no expectation to make up a coaching call if I do not cancel within the stipulated 24 hours before the start of the call.
YESNO

I agree to come to each call with total clarity about the goal and main area of focus for the call.
YESNO

I agree to abstain from alcohol and recreational drugs for the duration of our time working together unless explicitly addressed with me on a case by case basis (special occasion/wedding).
YESNO

I am fully committed and I’m in charge of my health and I will implement the advice given to me to the best of my abilities.
YESNO

I agree to disclose any psychiatric care or medications that are currently part of my regimen or arise at any point during our time working together.
YESNO

I agree to be fully transparent in my communication and respond to all messages within 48 hours.
YESNO

I agree to disclose any health issues, any family issues, and any changes or challenges that arise in my day to day life.
YESNO

I understand this service is not intended to be a substitute for my physician’s medical advice, diagnosis, or treatment. *Always consult with your medical treatment team (physician, psychiatrist, etc.) if you are suffering from a serious illness. I recommend that you combine my services with regular appointments with your primary medical practitioner.
YESNO

Please upload a photo of yourself. Make sure you are alone in the picture, standing straight, and fully clothed with your full-body visible in good lighting.

Signature: