Consultation Questionnaire

Thank you for your interest in coaching with Whole Again. This consultation questionnaire helps us understand where you are in your healing journey, what kind of support you are looking for, and whether coaching feels like the right fit for your current needs. Please answer only what feels comfortable for you — there are no “perfect” answers here. Your responses go directly and privately to Amy.

Personal Information

Full name

Preferred name (if different)

Email address

Phone number

Age

City & State

Consultation Questions

What led you to reach out for support at this time?

What are you hoping coaching will help you with?

Have you worked with a therapist, coach, support group, or healing program before?

Yes No Prefer not to say

If comfortable sharing, please briefly explain

How would you describe your current emotional wellbeing?

What patterns or challenges keep repeating in your relationships or emotional life?

What currently helps you feel emotionally safe, grounded, or supported?

What kind of support are you looking for most right now?

What are you hoping your life feels like six months from now?

Is there anything you would like me to know before our consultation?

Coaching Readiness & Expectations

Are you currently willing and able to: (check all that apply)

Attend sessions consistently Reflect honestly and openly Practice tools outside of sessions Approach healing gently and patiently Take responsibility for my emotional wellbeing Ask for support when needed

A Gentle Note About Coaching

Whole Again coaching services are educational and supportive in nature and are not therapy, mental health treatment, medical care, psychiatric services, or crisis intervention. Coaching may include emotional support, nervous system education, healing reflection, relationship pattern awareness, self-trust rebuilding, and practical healing tools.

If you are experiencing severe mental health distress, suicidal thoughts, domestic-violence danger, or a crisis situation, please seek immediate support from emergency services or a licensed mental health professional.

Client Acknowledgment

Please check each to confirm

I understand that coaching is educational and supportive in nature and is not therapy, mental health treatment, medical care, or crisis intervention.

I understand that healing is an individual process and that no specific outcomes are guaranteed.

I understand that coaching may involve emotional conversations and personal reflection.

I understand that I am responsible for my own wellbeing and participation, and that I will seek emergency or professional support when needed.

Signature

Typing your full name below is your electronic signature. By signing, you confirm that you have read and understand this questionnaire and the note above, and that the information you have provided is accurate.

Your name

Signature (type your full name)

Date

Personal Experience & Identification Disclaimer

Professional Scope