Full Name *

Date of birth *

State *

Country *

Timezone *

Are you working for yourself or someone else (W-2 or Entrepreneur)? *

Business or Business Idea *

How aligned do you feel with your career? Does this feel like your life’s purpose? *

Extremely! I was meant to do this

Meh ….I’m not aligned but I’m too tired to care (I just want to make enough money to live comfortably)

My job is not my life (I work to live, I don’t live to work)- I’m more of a clock-in and clock-out kinda gal

I hate my job/career and I’m still searching for my purpose

How authentic do you show up within your career? *

10/10= I’m me no matter what area of life

5= sometimes I’m genuine and sometimes I mask or pretend

0= I am a completely different person in my professional vs personal life

Relationship with Career *

Relationship with Sales *

Relationship with Social Media *

Relationship with Marketing *

Relationship with Deliverables/”showing up” *

My biggest career struggle right now is… *

What are your strengths? *

When it comes to work, I have a tendency to…. *

What are your weaknesses? *

Tell me your talents, gifts, passions, skills (regardless if you can make money off of it or not) - what do you love doing? *

Rate your morals, ethics, and integrity levels for others *

10 = very high/the highest

5 = some rules are meant to be broken

0 = I don’t care what people do

What is your relationship with money? *

What did you hear as a kid growing up about money?

What are your spending habits? *

Do you have and stick to a budget? *

Are you in debt? How much? *

Do you have a difficult time getting “simple tasks” done? *

Yes I have analysis paralysis (too much rolling in my brain so I do nothing)

I know what to do, and I know how to do it, but for some reason I just don’t

I have the time, I just don’t have the energy

It feels so overwhelming all the steps one tasks takes so I put it off until I absolutely have to

I do them, but not the way you’re “supposed to”

It is easy for me to get simple tasks/chores done

Other

When you hear the word “lazy” what comes to mind? *

When you hear the term “impostor syndrome” what comes to mind? *

Which one are you in your business: *

Realist

Pessimist

Optimist

What is your selfish motive for your business/career success?

What is your intrinsic motive for your business/career success? *

What does success look like to you? *

When someone tells you what to do, you…. *

I show up for myself (0= never, 10= always) *

I do the things I say I will (0= never, 10= always) *

I show up for others (0= never, 10= always) *

I trust myself (0= never, 10= always) *

I trust people who have proved to be trusted (0= never, 10= always) *

I trust others even if they have proven not to be trusted (0= never, 10= always) *

I do not trust others even if they’ve given me no reason not to trust them (0= never, 10= always) *

Have you ever worked with a coach or VA service before? Please rate your experience on a scale of 0= terrible, 10=amazing: *

What made it amazing? Or… If it was terrible, what did you need from them that they didn’t give you? *

Describe your relationship with your feminine energy *

What supplements/medication do you take *

What kinds of exercise do you do and how many times per week? *

Describe your typical evening routine. How do you unwind? *

What are your energy levels like throughout the day? *

Do you feel like you need to take a nap every day between 3-5pm? (select 1) *

Yes, and I do!

Yes, but I can’t

Yes, but I drink more coffee/energy drink to stay awake

No I do not feel tired throughout the day

What is your sleep schedule like? When do you go to bed and wake up? How many hours of sleep do you get? Do you feel rested upon waking? *

How much time do you spend on screens each day? Is it primarily for work, or is it mostly personal? *

How often do you get some sun/Vit D? *

Never

Sometimes

Every day

How often do you go outside? *

Never

Sometimes

Every day

What is your relationship with nature? *

Do you feel you are showing up authentically in your personal life? *

Do you show up differently in your personal life than you do in your career? *

What is the level of trust you have with your intuition? (10= completely trust, 0= don’t trust at all): *

What is your relationship with alone time? *

What is your relationship with your body? *

What is your relationship with stillness? *

Do you have chronic pain, illness, disease? Please list all of them below *

Where on your body do you feel each of the chronic symptoms? *

How often do you take time to acknowledge the pain in your body? *

When I experience moments of Overwhelm, my coping strategy is… *

When I experience moments of Stress/Anxiety, my coping strategy is… *

When I experience moments of Fatigue, my coping strategy is… *

When I experience moments of Burnout, my coping strategy is… *

When I experience moments of Brain Fog, my coping strategy is… *

When I experience moments of Anger, my coping strategy is… *

When I experience moments of Sadness, my coping strategy is… *

When was the last time you cried? *

When was the last time you raged? *

When was the last time you laughed? *

Do you know your love language, to give? *

Do you know your love language, to receive? *

Do you have any diagnosis (professional or self diagnosed)? *

Are you religious or spiritual? Please explain *

What are some triggers and/or pet peeves you have? *

What inner healing work have you done in the past? *

What is your relationship with your period, PMS, etc? *

Describe your period symptoms: *

How regular are you? *

Do you take anything for the pain? For how many days? *

Do you use anything else to help with the pain? *

Are you on birth control? *

What is your diet like during your period? *

What is your diet like 5 days before your period? *

What is your exercise/movement like during your period? *

What is your mood like 5 days before your period? *

What is your mood like during your period? *

Scale of 0=low to 10=high, rate your level of exhaustion *

Scale of 0=low to 10=high, rate your level of fatigue *

Scale of 0=low to 10=high, rate your level of overthinking *

Scale of 0=low to 10=high, rate your level of anxiety *

Scale of 0=low to 10=high, rate your level of depression *

Scale of 0=low to 10=high, rate your level of brain fog *

Scale of 0=low to 10=high, rate your level of controlling outcomes *

Scale of 0=low to 10=high, rate your level of self control *

Scale of 0=low to 10=high, rate your level of impulsivity *

Scale of 0=low to 10=high, rate your level of self worth *

Scale of 0=low to 10=high, rate your level of avoidance *

Scale of 0=low to 10=high, rate your level of attachment to achievement *

Scale of 0=low to 10=high, rate your level of seeking external validation *

Scale of 0=low to 10=high, rate your level of oversharing *

Scale of 0=low to 10=high, rate your level of overgiving *

Scale of 0=low to 10=high, rate your level of boundaries *

Scale of 0=low to 10=high, rate your level of fear of failure *

Scale of 0=low to 10=high, rate your level of overwhelm *

Scale of 0=low to 10=high, rate your level of unclear goals *

Scale of 0=low to 10=high, rate your level of stress upon waking (short answer)

Scale of 0=low to 10=high, rate your level of stress at work *

Scale of 0=low to 10=high, rate your level of stress before bed *

Scale of 0=low to 10=high, rate your level of people pleasing *

Scale of 0=low to 10=high, rate your level of perfectionism *

Scale of 0=low to 10=high, rate your level of authenticity *

Scale of 0=low to 10=high, rate your level of taking the lead *

Scale of 0=low to 10=high, rate your level of surrender *

If all your struggles and pain disappeared, what would you have the freedom to do? *

Are you interested in receiving guidance on nutrition, exercise and cycle syncing to your period to support your body and feminine mind? (I am not a doctor and I cannot give medical advice, I can only share my experiences in the hopes that they help you in some way.) *

Yes

I’m interested to hear what you have to say

Other

I am a NLP and TLT certified coach. Would you be interested in receiving mental health coaching that will support both your personal and professional life? *

Yes

I’m interested

Other

On a scale of 0-10, how committed and ready are you to take control of your mental health, your physical health and the wellbeing of your career? *

Is there anything else you’d like to share? *