Evaluation Form

Michelle Bersell Life Coaching Evaluation Form (All responses are confidential!)

Your Name

Address

City

State

Zip

Your Email

Phone

How did you hear about Michelle Bersell.com?

Birthdate

Relationship Status

__________

How would you describe your current challenge, problem or block?

How long have you had this problem, challenge or block?

On a scale from 1-10, how much does your current challenge, problem or block impact you in the following areas?

( 1=very minimally impacts my life to 10 = extremely impacts my life)

Self Esteem

Career

Relationships

Physical Health

On a scale from 1-10 how much do you believe others contribute to your problem, challenge or block? Please describe:

If in a committed relationship, is your partner supportive? Please Describe:

Do you have children?
 Yes No

If so, please describe their ages and any struggles that you may be facing with them.:

Does anyone in your family (immediate or extended) have problem, block or challenge similar to yours?:
 Yes No

If so, please describe:

__________

Occupation

Please rate your stress levels on a scale of 1-10 (10 being high): Stress Levels:

How would you rate the pace of your life: Very fast paced Busy, little free time Moderate Slow, Relaxed Pace:

____________

Do you have any health issues?  Yes No

If yes, please provide more information:

How do you sleep at night?:

What time do you normally go to bed and normally rise?:

How do you typically feel upon waking?:

Have you or a family member had any recent surgeries or serious illnesses?:  Yes No

If yes, please explain:

__________

Questions for Women

Do you experience PMS symptoms.: Yes No

If so, please describe:

__________

Do you have challenges with your weight?:  Yes No

Do you eat when you are bored?: Yes No No, or stressed  Yes No

How often do you exercise?:

__________

Have you tried therapy or life coaching programs in the past?: Yes No

If so, were they successful?:

Please list any current psychotropic medications you are taking:

What is your ideal outcome?

Do you think you are ready for getting this type of support? : Yes No

Anything else?

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