Emotional Wellness Questionnaire

First name

Last name

Phone

Age

Gender

Cultural Background

Relationship Status

Have you previously sought any health services, such as therapy or counseling? If so, please share your experiences.

What are your primary goals for personal development?

What challenges are you currently facing in achieving these goals?

Have you previously worked with an accountability framework or coach? If so, please share your experiences

What are your expectations from this accountability program?

How do you prefer to receive feedback and guidance? (e.g., email, phone calls, face-to-face meetings)

What are your hobbies and interests outside of work?

Do you have any health considerations we should be aware of?

How would you rate your current level of physical activity? (Low, Moderate, High)

Describe any significant obstacles or challenges you've encountered in past personal development efforts:

Is there any other information you think is important for me to know to better understand and assist you?

I confirm that the information provided above is accurate and consent to share this information for the purpose of our sessions.

Thanks for submitting! Please read through the framework and complete your motivator, prior to your first session.

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