Request A Discovery Session – Collective Consciousness Life Coaching

Personal Information Sheet

All information is completely confidential and will be held as such. Provide answers for that which applies to you and would be effective for our coaching relationship (some of the information may not apply to you, or is irrelevant to our working together. totally up to you). You can add explanations (More details on another page) where you think you would like to further explain any thoughts or feelings to me.

Mailing Information

Full Name

Name you would like to be called

Mailing Address

Street address, if different

City, State/Province, Zip/Postal Code

Country

Personal Numbers:

Home

Face time

Mobile

Fax

In case of emergency

Website

Email

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To give me permission to use your email? I would never sell or give your email to any other party for any reason.

Work Information

Occupation

Employer’s name

Employers address

Work telephone

Personal Information:

Date of birth

single in partnership married divorced widowed other

Primary partner’s name and date of birth

Other significant dates: (e.g. wedding anniversary, sobriety anniversary, etc.)

Credit Card Information

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Disclaimer

By providing your credit card information in this discovery packet, you authorize us to securely keep your card on file for future services. Your card will not be charged without prior notice, except in the event of a missed appointment or cancellation made without at least 24 hours’ notice.

If a session is not canceled or rescheduled within the required 24-hour timeframe, you acknowledge and agree that we reserve the right to charge the card on file accordingly.

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By submitting your information, you confirm that you understand and accept this policy.

Client Questionnaire

The following questions are to help kick start our coaching together. There are no right or wrong answers. Have fun and give yourself the time you need to both review and chew on your answers. Use extra space to answer the questions completely.

1. Pretend that you are near the end of your life. In looking back, what would you have needed to do/see/experience in order to consider your life to be one of fulfillment? Of few or no regrets?
2. Take time to describe your passions. What are they? Where in your life do they show up? Where don't they? If you were to tell me of a secret passion, one that is almost too exciting to do or do more of, what would it be?
3. What would you like me to know in order to be the best possible coach for you? What tips could you give me to coach you most effectively?
4. What's missing in your life, the presence of which would have your life be more fulfilled?
5. Some of the following questions I have borrowed from James Lipton, the host of the television show Inside the Actor's Studio (who borrowed them from a French journalist). The others I either created myself or have heard other coaches use. Please answer them spontaneously. If you find that you have more than one answer, that is fine, too. Write down your first thoughts, as they tend to be the most natural and unguarded (do not think too much before you write!!!):

a. If you were to do any job other than the one you have now, what would it be?

b. What would be the last possible job you would ever consider taking?

c. What is your favorite word?

d. What is your least favorite word?

e. You are about to spend 4 months alone on a deserted island where all of your food, clothing and shelter needs will be taken care of. What 10 items will you bring with you?

f. What is one of your most embarrassing moments?

g. What is your favorite song?

h. What would your dream house look like on the outside?

On the inside?

i. You have just won $50 million dollars in the state lottery. What will you do?

j. If I were to interview your family and closest friends, what would they say are your strengths?

Your weaknesses?

k. If you could be any superhero, who would you be? What powers would you have?

l. You have been chosen to host a dinner attended by any 7 guests of your choice, living or dead, real or fictional, famous or unknown. Who would you invite? What sort of conversation would take place? How would the evening unfold?

m. What class(es) were not offered in school that would have helped you most?

n. What is your favorite food?

o. What is your least favorite food?

p. Describe your ideal vacation.

q. If you were to receive a tattoo on a place on your body where none could see unless you chose so, what word(s) and/or image(s) would you choose?

r. What is your favorite book?

s. What is your favorite movie?

t. If you were to write and direct a movie, what would the plot be about? Who would star in it? What would the setting be?

VALUES

In coaching terms, values represent who you are and what is essential to you. They are not universal morals, nor are they standards of good and evil. They are not things that come and go, or principles that you develop over time. Values represent that which, if honored fully, will bring immense fulfillment to your life.

At the start of our process, we will look at and clarify your top values, and then refer to them often in our ongoing work together.

Spend some time with the exercises on this page. They are intended as the first step in naming your values. What you write based on these exercises will be used by us as raw material. Do not worry about naming the actual values. We will do that together.

1. Think of a peak time in your life, a time of extreme pleasure or adventure, learning or satisfaction, peace or well-being. It may be a moment in time, or may have happened over a long period. Describe this time, with as many pertinent details as possible. What was it about this moment or experience that made it so powerful? Put yourself back in that time, and be aware of all around you. What do you see? Hear? Taste? Smell? Feel? What thoughts are in your head? What emotions are you experiencing?
2. Think back to a terrible event, moment or period in your life, a time where you felt completely dishonored, unloved, disempowered - a truly yucky time. Describe this time, with as many pertinent details as possible. What about it was so horrible? What aspects of that time do you never want to experience again? Put yourself back in that time, and be aware of all around you. What do you see? Hear? Taste? Smell? Feel? What thoughts are in your head? What emotions are you experiencing?
3. What really makes you angry/drives you crazy?
4. If I were to interview your family and/or closest friends, what would they say you value the most?

Please rate the following symptoms using the number key below.

Please check any current or past issues that still affect you.

Have you ever been hospitalized for psychiatric care or a mental disorder, or has a physician, psychiatrist, or mental health professional ever recommended such hospitalization to you?

Yes
No

Are you currently in therapy?

Yes
No

If yes, have you informed your therapist that you are enrolled in coaching?

Yes
No

Within the past six months have you taken, or has a health professional advised you to take, any prescription medications or drugs that a) affect your mental processes or mood, b) to treat a chemical imbalance, or c) to treat depression or a mood disorder?

Yes
No

Why do you want to work with me?

How or Where did you learn about me?

Any other information you would like to share with me?

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Please sign to give me permission to work with you.

I am willing to be guided through relaxation techniques, visual imagery, creative visualization, hypnosis, neuro-linguistic programming (NLP), emotional freedom techniques, and other energy-based practices. I understand that all services provided—including hypnotherapy, coaching, and NLP—are non-medical in nature. For any medical concerns, diagnoses, or changes in medication, I will consult my qualified healthcare practitioner.

I acknowledge that I have been fully informed about the nature and purpose of these services, and I have had the opportunity to ask any questions prior to participation.

I understand and agree to the policies of Collective Consciousness Life Coaching. All sessions are paid in advance. The initial session is a 40-minute consultation priced at $47, which must be paid upfront and is non-refundable.

There is no refund policy for any services. A minimum of 24 hours’ notice is required for any appointment cancellation or rescheduling. Failure to provide sufficient notice may result in the session being forfeited.

You will be contacted at the agreed-upon time and number for each scheduled session. If you are unavailable at that time, a message will be left, and you may return the call within the scheduled session window to utilize your remaining time. If any changes or delays occur on the provider’s end, you will be notified via text, and adjustments will be made accordingly with your agreement.

For any communication regarding scheduling or issues, you may also reach out via text at 1-602-315-6300. We understand that unforeseen circumstances may arise, and we will work together professionally to address them.

Thank you for your cooperation. I look forward to working with you.

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