Name

First Name

Last Name

I am interested in:

Improving my nutrition

Improving my sleep

Improving my stress management

Improving my movement and exercise

Other (Not Listed)

What specific problem would like us to help you solve?

Why is it important that you solve this problem? Why now?

What are the consequences of NOT solving this problem?

Have you previously tried to solve this problem?

Where do you see your future self if this problem is not addressed?

What personal and social strengths do you have that be implemented to achieve these goals?

Ex: Ambitious, Coachable, Communicative, Curious, Dedicated, Determined, Experience, Attitude, Knowledgeable, Motivated, Organized, Positive, Self-Managed, Skilled, Supported by Friends and Family, etc

What personal and social weaknesses can you personally identify that might hold you back?

Palm Beach Health Coaching