INTAKE QUESTIONNAIRE

✨Hey there! Welcome to your first MIDLIFE STRUT coaching session!

I am thrilled you're here - and so excited to work with you!

Please fill out the form below and return it to me before your first session.

Name

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Name and cell #:

May I communicate with you via text or the Telegram app?

Yes

Who do you live with? Kids? Spouse?

What are you struggling the most with right now that you are eager to work on and change? What have you already done to try to address these struggles?

Have you worked with a coach or therapist before? If so, what was the outcome?

What would be the best thing you can think of that you would love to walk away with having worked with me? In other words, what results are you looking to achieve?

What is getting in the way of you living your best possible life?

On a scale from 1-10, with 10 being the highest, how committed are you to reaching the goals and resolving the issues you shared on this form?

What big questions do you have for me? What feels like a challenge, or a big question mark, or anything that seems overwhelming or confusing?

How did you learn about Jana Fuchs Coaching, LLC?

Please share 3 wins you've had over the last 12 months.

Today’s Date:

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