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1:1 Visualization Coaching Application
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Thank you for your interest in coaching with
Faith Helps, LLC
! Before your
free 30-minute consultation
, please take a few moments to complete this screener.
Your responses will help me:
Understand your goals and expectations
Ensure coaching is the right fit for your needs
Prepare for a productive and focused consultation
Instructions:
Please answer all questions honestly and as thoroughly as you feel comfortable.
Your responses are confidential and will be used only for the purpose of preparing for your coaching consultation.
If any question does not apply, feel free to write “N/A.”
This screener does not replace professional mental health care. If you are experiencing thoughts of harming yourself or others, please seek immediate support from a licensed mental health professional or call emergency services.
*
1.
First Name/ Last Name
(Required.)
*
2.
Email Address
(Required.)
*
3.
Phone Number
(Required.)
*
4.
Current State of Residence
(Required.)
*
5.
What interests you most about Visualization Coaching at this time?
(Required.)
*
6.
Have you ever engaged in guided imagery, visualization, meditation, or mental rehearsal exercises before? If yes, please describe your experience.
(Required.)
*
7.
Do you ever experience dissociation, spacing out, losing chunks of time, or intense difficulty staying mentally present? (If yes, please describe to the extent you feel comfortable)
(Required.)
*
8.
Are there any ongoing safety concerns or medical conditions that you feel the coach should know about?
(Required.)
*
9.
All sessions are held virtually via Zoom. Please confirm you have access to a private, quiet space and reliable internet for your scheduled sessions.
(Required.)
Yes
No