Client QuestionnaireThank you for taking the time to complete this form, which will help me provide the best possible coaching and learning experience for you. Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *PhoneAddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCoaching DesiresPlease check the coaching and learning opportunities you are interested in? *Online CoachingEquine-Assisted Coaching & LearningHighlands Ability BatteryPersonal Vision CourseOtherPlease describe what you hope to gain from working together?Are you currently working with a coach for personal or professional development? *YesNoPrefer not to answerIf yes, please feel free to briefly describe.Wellness InformationBirthday (month/date/year) *Are you currently in the care of a doctor and up-to-date on your wellness visits? *YesNoPrefer not to answerAre you struggling with any physical health issues? *YesNoPrefer not to answerIf yes, please feel free to briefly describe.Are you currently in the care of a mental health provider, such as a therapist, counselor, psychologist, or psychiatrist? *YesNoPrefer not to answerIf yes, please feel free to briefly describe your treatment plan.If you are taking any medication, please list below and include dosage amount, purpose of medication, and when you began taking it. Please check if you struggle with or have experienced any of the following:addictive behaviorsalcohol useanxietyangerchronic health issuesdepressiondifficulty concentratingdifficulty sleepingdrug useemotional outburstsfatiguelonelinessrelational conflictsself-harmsuicidal attemptssuicidal thoughtsemotional abusephysical abusedomestic abusesexual abusetraumatic eventloss of loved onefamily member's addictionbetrayalPlease check if you have been diagnosed with any of the following:anxietydepressionalcohol addictiondrug addictionsmoking addictionporn addictionborderline personality disorderobsessive compulsive personality disorderobsessive-compulsive disordernarcissistic personality disorderpost-traumatic stress disorderPlease feel free to share anything you believe would be helpful in understanding your situation and/or coaching desires:How did you hear about us?lisapulliam.comstableminded.usmoretobe.comhorseclass.comHoney Brook StablesWomens Business ConnectionFriendFamily MemberEventFacebookPinterestInstagramLinked InOtherIf friend or family, please share their name:Submit
