Client Questionnaire

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 Exploration. Of Co-Creation, Radical Responsibility, and Sovereignty.

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.

Legal 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/Listening Space
Integrated Attachment Theory Relationship Coaching
Communicating Boundaries & Needs Training (one on one with me, includes role play)
Quit People Pleasing Transformation Role Play Workshop
Conscious Sex & Intimacy Guidance
Bespoke Healing
More than 1 offering (type details below)

If you selected Bespoke Healing OR more than 1 offering, please inform me about what you'd like to work on 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: *