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All of your information will remain confidential between you and the Health Coach.


The contents of this website are for informational purposes only and are not intended to be a substitute for professional medical advice, diagnosis or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.

Life Esteem Circle of Wellness

Transformational Coaching

All of your information will remain confidential between you and the Coach.

I look forward to seeing you at our next session!

You have two options when completing the Health History. 1) Fill out the form below and press the "SUBMIT FORM", OR 2) Download a copy of the Transformational Coaching Form (download here), fill out form, and email it to



Last Name*

Email Address*

How often do you check email?

Home Phone:*

Work Phone:

Moble Phone:



Place of Birth

Emergency Contact Name



SOCIAL INFORMATION - Relationship status

Where do you currently live?




Hours of work per week

Is your job/business stressful?*

HEALTH INFORMATION - Are you presently under a doctor’s care?*

Select an option

If yes, please describe?

Doctor’s Name: (We do not contact your doctor as a standard practice)

Are you currently taking prescription medication?*

Select an option

If yes, please describe?

Are you now or have you ever been treated by a mental health professional? *

Select an option

If yes, please describe?

Please check any of the following health conditions that apply:*

If you checked Pain, where is the pain?

If your checked Other Diagnosed, please explain

REGARDING COACHING - 1. What is your primary reason(s) for coaching?*

2. What benefits will you gain once your desired objective(s) is reached?*

3. What are you expecting to happen by using a coach?*

4. What is the most empowering and helpful thing I can do for you during our sessions?*

5. How will you know that your coaching was successful?*

ABOUT YOU - 6. Please list 3 things you like best about you.*

7. What are you most passionate about?*

8. What do you like most about your life now?*

9. What do you like least about your life right now?*

10. Where do you want your life to be one year from now?*

11. In what area(s) would you like to grow and experience positive change within yourself?*

12. What is one thing you could do in your personal and/or professional life that, if you did on a regular basis, would make a tremendous difference in your life?*

13. Would those who know you best say that you are more outspoken or more reserved? On a scale from 1 to 10 with 1 being very reserved and 10 being very outspoken, which number are you?*

Select an option

14. Would those who know you best say that you are more emotional or more logical? On a scale from 1 to 10 with 1 being very emotional and 10 being very logical, which number are you? *

Select an option

15. On a scale between 1 (lowest) and 10 (highest), where would you currently rate your self-esteem?*

Select an option

ABOUT YOUR BLOCKS - 16. What do you believe is holding you back or blocking you?*

17. What benefits do you gain by NOT reaching your objective(s)?*

18. What fears do you have concerning moving forward with your objective(s)?*

19. What is the most critical thing(s) you say to yourself?*

ADDITIONAL INFORMATION - Have you ever used coaching before? *

Select an option

If Yes, how long ago?

What did you like MOST about your previous coaching?

What did you like LEAST about your previous coaching?

ADDITIONAL COMMENTS - Anything else you would like to share?

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