Discovery Intake Form / Thank You / Let's Talk! / Coaching | Gracefully Restored Life & Wellness Coaching

First Name *

Last Name *

Email address *

Phone Number *

City, State *

How May I Contact You? *

Phone
Email

What are three things that you feel are hindering you? Which ones made it hard to reach your goals? *

What do you value most in your life right now? *

What are your short-term goals for the next 3 months? *

What has your biggest SUCCESS been so far? What did you do to accomplish it? *

On a scale of 1 to 5, with 5 being the highest, what is your CURRENT level of stress? Please check one. *

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5

On a scale of 1 to 5, with 5 being the highest, how would you rate the QUALITY of your life today? *

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3
4
5

Who has been supporting you so far? *

Anything else you would like for me to know?

Discovery Intake Form