Forms Site

Name

First Last

Email

Cell Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Organization

Role with Organization

How many years have you been with this organization?

In the past, have you received the following services? (check all that apply)

Spiritual Direction
Counseling
Nutrition Coaching
Personal Training
Life Coaching
Gym Membership
None of the above

Currently, are you receiving any of the following services? (Check all that apply)

Spiritual Direction
Counseling
Nutrition Coaching
Personal Training
Life Coaching
Gym Membership
None of the above

If you do receive the above services, how often do you receive them?

Have you taken any personality assessment tools (Enneagram, Myers-Briggs, DISC, StrengthFinders, etc)? If yes, please list your types and/or strengths below if you know them:

In what ways do you feel like you’re currently practicing self-care?

What is preventing you from practicing self-care?

I understand that enrolling in a self-care plan with Coach Approach/Day 7 will require time, effort and energy on my part. I will respond to emails and communicate effectively and timely regarding my plan. I am willing to take the time to invest in myself and my own self-care.

I agree
I am not able to commit to this at this time, but would like to stay on the list for the future.

Client Intake Form