Coaching Application — Larisa Jayne

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Larisa Jayne

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Larisa Jayne

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Coaching Application

Please complete the form below.

This application has been designed to understand your goals, so I can make sure I am the right coach for you.

Once completed and accepted, you’ll be contacted to organise a free phone call.

All information provided will be kept confidential.

Larisa

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Personal Details

Name *

First Name

Last Name

Preferred Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email *

Mobile *

Date of Birth *

dd/mm/yyyy

Current Age *

Gender *

Other (Gender)

Tell me about yourself *

Why are you here? What changes do you want to make in your life?

What is your current #1 goal for the next 3 to 6 months? *

Line

Have you had Kinesiology before? *

Yes

No

What other help have you sought so far?

Acupuncture

Chiropractic

Counselling

GP / Doctor

Naturopathy

Psychology

Psychiatry

Reiki

Other

Other

Other help

Tick all that are applicable past or present

Abuse

Addiction

Aggression / Anger

Bullying

Depressive Thoughts

Emotional Pain

Family Stress

Fear

Financial Stress

Friendship Stress

Grief

Isolation

Loneliness

Lack of Motivation

PTSD

Panic Attacks

Self-Control

Self-Esteem

Self-Sabotage

Sleeping Issues

Trauma

Trust Issues

Unhappiness

Work Stress

Other (describe below)

Other

other stressors

Lifestyle

Current Stress Levels *

Usual Stress Levels *

Are you 100% ready to take action in your life now? *

This involves inner work and commitment to showing up and doing the work

YES 100%

Maybe

No, I'm not quite ready

Do you have any questions?

Declaration *

I declare that the above information is true and current.

I Agree

DATE *

dd / mm / yyyy

Thank you!