Intake — Dr. Dawn's Coaching Place

Initial Intake Questionnaire

The following questions are optional but can help guide the initial direction of coaching. Before submitting this form you will be asked to acknowledge that you have read and understand the Waiver & Disclaimer and the Coaching Agreement .

Name

First Name

Last Name

1.. What do you always find time for?

2. How much time do you spend on social media each day?

3. Have you undergone any major life transitions in the last two years? Please list personal losses, death of loved ones, loss of job or home, etc.

4. What would you like to contribute to to the world?

5. Do you have repeating patterns that you would like to change?

6. Do you have problems when making changes?

7. What message would you like to say to the next generation?

8. Have you been diagnosed with Post Traumatic Stress Disorder? If so, when and why did this occur?

9. Have you had postdelivery complications? What were the symptoms?

10. Do you have premenstrual syndrome? Are you receiving treatment?

11. Have you lost family members to Covid-19? Have you been treated for bereavement issues?

12. Please describe how you spend your typical day, for example, employment, caring for children, hobbies.

I have read and understand the Coaching Agreement

Yes

I have read and understand the Disclaimer

Yes