Intro to Coaching Questionnaire

New Client Health Coaching Intro Questionnaire

1. Please fill out the form below and Dr. Meghan will be in touch shortly.

Name *This question is required.

Street Address

Apt/Suite/Office

City

State

Postal Code

Country

Email Address *This question is required.

Phone Number

Mobile Phone

Website

2. How did you hear about Dr. Meghan Birt?

3. How can Dr. Meghan help you? What are your main symptoms?

4. What are your health goals? (ex. better digestion, weight loss, increased energy). What is your time frame?

5. If I could help you with ONE thing, what would it be?

6. What's your favorite thing to do in life? What makes you happy? Have some fun here!

7. Rate your level of commitment to change your lifestyle to change your health? (nutrition, exercise, supplementation, detoxification) 1 is the lowest and 10 is 100% committed.

8. Why did you rate your commitment level at the number selected? If not a 10, what would get you more committed? (more information, not sure if you're ready to change, fear, unwilling to change at this time, etc.)

9. How would you describe yourself in 3 words?

10. If you could sing one song on American Idol, what would it be? (Once again, just have some fun here)