IF YOU’RE READY TO
LIVE WITH MORE JOY
AND LESS (OR NO) PAIN,
THEN LET ME GUIDE YOU

1) I am

MaleFemale

2) Are you in pain right now?

YesNo

3) I am in my

30’s40’s50’s60’s70’s80’s

4) What is Your Relationship Status?

SingleMarriedDivorcedRemarriedCommitted Relationship

5) Briefly describe your childhood in relation to your family of origin (joyful, unstable, siblings, adopted/fostered, uneventful, etc)

6) What do you enjoy doing in your life?

7) On a scale of 1-10 (1 being “I can’t get out of bed in the morning” and 10 being “I am very HEALTHY”), rate your current physical health:

8) On a scale of 1-10, (1 being "I'm sad and anxious all the time" and 10 being “I am very HAPPY”) rate your current emotional health:

9) What is the most difficult or greatest struggle in your life right now as it relates to pain?

10) If you could pinpoint the single greatest health challenge you have right now, what would it be?

11) What are 2 to 3 reasons why you haven’t overcome your current health challenge?

12) What ELSE may be LACKING in your life that’s keeping you STUCK and stopping you from achieving your goals and having what you want?

13) What specific daily symptoms do you notice (physically and mentally) that are preventing your optimal health?

14) If you had more time, what would you do more of (that you would love to do) but you can’t because of your health challenges?

15) What treatments have you tried to heal your current health challenge?

16) What is your vision of what you’d like your health to be like 12 months from now? What would life be like?

17) How long have you been working on getting out of physical and/or emotional pain?

Less than 1 year1-2 years3-5 yearsOver 5 years

18) List things that bring you joy, that settle you, make you feel like yourself, or bring pleasant feelings: places, people, pets, experiences, etc.

19) Have you ever invested in coaching to get you out of your current health situation? If not, why not? If yes, provide details below.