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Name*
Age
Email*
Phone*
What 1:1 Coaching Service are you most interested in?
Referred by/How did you hear about Gina?
What is your initial interest in applying for this program?
What is most important to you right now in your daily life?
What do you need right now in your daily life?
What is the result you are looking for?
What do you want to feel in your everyday life?
What inspires you to take action?
What is your purpose in choosing to work with Gina right now?
When do you want to get started?
What is the timeline in reaching your results?
Have you worked with a coach before? If so, what experience have you had?
Please tell me more:
What amount of time each week are you willing to put into this coaching experience?
For the following questions, rate your answer on a scale from 1 to 10, with 10 being the best or the most.
What do you scale your self talk?
Please enter a number from 1 to 10.
What do you scale your self-esteem?
Please enter a number from 1 to 10.
What do you scale your self-confidence?
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What do you scale your health?
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What do you scale your mental strength and endurance?
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What do you scale your physical alignment?
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What do you scale your ability to take risks?
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What do you scale the vision of your life?
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What do you scale your clarity of purpose?
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What do you scale your willingness to take action?
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What do you scale your willingness to change?
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What do you scale your willingness to receive?
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What do you scale your willingness to invest?
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What do you scale your willingness to be present?
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What do you scale your willingness to do your self-work?
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What do you scale your willingness to be still?
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What do you scale your willingness to be uncomfortable?
Please enter a number from 1 to 10.
What do you scale your willingness to share authentically?
Please enter a number from 1 to 10.
What do you scale your willingness to listen to your intuition?
Please enter a number from 1 to 10.
What do you scale your willingness to be patient?
Please enter a number from 1 to 10.
What else do you feel the need to share with Gina?
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For the following questions, rate your answer on a scale from 1 to 10, with 10 being the best or the most.