BodyMind Coaching application

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* 1. What is your name and your email address?

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* 2. What area(s) of your life are you experiencing the most struggle and stress? List any symptoms you experience, including depression, anxiety, GI issues, pain, women's health issues, fertility, headaches, anger, etc.

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* 3. What do you currently do to relieve stress? (for eg. a glass of wine at the end of the day, food, massage, yoga, numbing out in front of the tv, etc). How effective have these strategies been?

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* 4. If nothing changes, where do you see yourself in 10 years?

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* 5. Why are you interested in BodyMind Coaching?

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* 6. On a scale from zero to Chuck Norris, how awesome are you?

0

10

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 7. How do you want to feel?

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* 8. On a scale from 1 to 10, how committed are you to making a change?

0

10

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 9. I notice that women struggle with consistency in self-care + they tend to only seek me out when they are in pain. If you are accepted into the BodyMind Coaching program Kirstin offers, do you promise to show up for yourself + make yourself a priority?

Yes

No

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* 10. The most loving thing I can do for you is get you to invest in yourself. When you allow yourself to receive support, your whole life can change and you allow those in your life to receive. Are you willing to go all in on yourself?

Yes

No