Client Questionnaire

Hello dear! Before filling this out, I’d like you to read and FEEL these words ➤ My Evolution is Now.

In this moment, every part of your body, mind, and soul is in the state of evolution. You are now choosing to be aware of this moment that you get to embody!

You are aware: You are Consciousness.

And your presence while in the expansion of it is how all healing and personal development, transformation and creation happens.

The time is now. It’s always now.

We’re crossing paths for a reason. How can I serve you as a priestess of Gaia?

This is a space of co-creation.

There is no hierarchy and I’m committed to taking Radical Responsibility.

There are no “right” or “wrong” answers to the questions below. Share what needs to be shared such as your history/background, personality, and anything important for me to know in order to understand and work with you.

This is a space of Love, Integrity, and Authenticity.

Vulnerability—the touchstone of Growth—is welcome. Your feelings are welcome. ALL parts of you are welcome.

It’s a space of Exploration, Transformation, and Creation.

Namaste! 🪷

For bespoke in-person healing: Please inform me of any health issues so that we can plan accordingly.

For general inquiries, email me at HolisticJuniper@proton.me.

Name *

First

Last

Phone *

Email *

Date of Birth *

What City Are You Based In? *

Availability (Please provide Me with *ALL* the times & days you are available throughout the week/month. Include weekends if you're open to them. Please give me a broad range so I can plan better for us.) *

Please Select the Offering/s You Desire *

Spaceholding
Holistic Self Development Coaching
Relationship Coaching through Integrated Attachment Theory
Assertiveness & Boundary Training Through Role Play
Conscious Sex & Intimacy Guidance
Bespoke Healing

If you selected Bespoke Healing, please inform me about what you desire below

What are the biggest life changes you want to make in the next 6 months? How about the next two years? *

What, if anything, do you feel is holding you back from achieving your short and long term goals/changes? *

What Are Your Goals/Intentions From Our Coaching Relationship? *

What Is It That Draws You to Me? *

How Did You Find Out About Me? *

What are your 3 greatest accomplishments in life so far? *

What has been the biggest challenge of your life to this point? How did you manage that challenge, and what has its impact on your life been? *

What major transitions/life changes have you had in the past two years? (i.e. entering/leaving a relationship, changing careers/locations, you and/or your children entering different age group, tragedy/serious hardship/crisis. No need to go TOO deep into detail here, write as much as you are comfortable with and will support our relationship) *

What do you love about your life and who you are? What do you dislike/feel negatively about in your life and who you are? *

Have you ever worked with a life coach before? If so, what worked/didn’t work about that relationship? What is important to you in a coaching relationship to feel fulfilled and supported? *

Please write anything else you think is relevant for me to know about you for our coaching relationship. This can be current struggles or positive situations, important aspects of your personality, things that trigger you, things that make you happy, etc. *

Any questions or other communication regarding the session: *