Welcome!

Hey there! Excited to start this journey with you!

Before we dive into our weekly routine, there’s one first step – the Beginning Blueprint. This “get-to-know-you” form helps us get to know each other before our first meeting. Think of it as building the foundation for something awesome!

Take your time with it, share what feels comfortable, and remember, some parts are key for a strong start. But most importantly, your honesty and comfort matter most to me. Be yourself, completely!

Got questions or need help? Don’t hesitate to reach out! Let’s make this an amazing adventure together!

Plus Check
Beginning Blueprint

Name(Required)

First Last

On a scale of 1 (not at all) to 10 (I'm languishing in success), how close do you feel you are to reaching your current goal(s). Please share any information relevant to this.(Required)

On a scale of 1 (none) to 10 (rocking it), how close do you feel you are to reaching your current goal(s).

Please share any information relevant to this.

How are you feeling this week?

On a scale of 1 (none) to 10 (extremely distressed), how severe do you feel your symptoms of burnout have been this week?

What was your biggest achievement this past week?

Did you encounter any obstacles or challenges? How did you address them?

What have you learned about yourself this week? What mindset shifts did you expereince?

Is there anything you've been doing that you find particularly helpful or unhelpful?

What goal would you like to focus on for the coming week?

How can I support you better in the upcoming week?

Is there anything else you'd like to share or discuss?

Name(Required)

First Last

Phone(Required)

Email(Required)

Pronoun

She/her

He/his

They

Other

If other, please identify

Time Zone(Required)

On a scale of 1 (just starting) to 10 (you've reached enlightenment), where do you place yourself in you mindset/personal groath journey?(Required)

Have you worked with a coach or mentor before?

Yes

What was your experience? How was your relationship with them?

What did you really enjoy about your expereince with them? Were there specific guidance or techniques you found useful or not useful?

Have you ever received mental health treatment (therapy, counseling, psychiatric medication, etc.) in the past?

Yes

Describe your experience. Was it helpful? If not, why not?

Are you currently under the care of a mental health professional (such as a psychiatrist, psychologist, or counselor)?

Yes

Would you be open to signing releases for us, myself and your therapist to collaborate?

To ensure we're working in harmony towards your well-being, I suggest collaborating with your therapist. This teamwork approach helps us stay aligned, ensuring our advice complements each other and supports your journey without confusion or mixed messages. Your consent for this collaboration is vital and deeply appreciated, as it underscores our unified commitment to your growth.

Yes

What were/are diagnoses were you given?

Yes

Please specify the diagnosis/diagnoses:

Have you ever attempted suicide?

Yes

Please provide any details you are comfortable sharing:

Have you ever had suicidal thoughts?

Yes

Please provide any details you are comfortable sharing:

Are you currently experiencing suicidal thoughts?

Yes

If you are currently experiencing suicidal thoughts, I strongly encourage you to call 988 or to seek immediate assistance from a mental health professional via emergency services.

Mindset and Goals

Describe your current mindset and attitude towards personal and professional life:

What specific goals are you hoping to achieve through mindset mentoring?

Challenges and Expectations

What are the biggest challenges you are currently facing?

In what areas of your life do you feel you need the most improvement?

What are your expectations from the mindset mentoring sessions?

Gain new perspectives

Develop better coping strategies

Enhance personal growth

Other

If Other, please specify:

Lifestyle and Interests

Describe your typical daily routine:

What are your goals, hobbies, and interests outside of work?

Health & Wellbeing

How would you rate your overall well-being on a scale from 1 (not well/sick) to 10 (optimal health)?

Please explain your rating:

What does your typical physical activity routine look like?

Daily

Weekly

Occasionally

Rarely

Details (e.g., types of activities, frequency):

How would you describe your eating habits?

Balanced and nutritious

Variable but mostly healthy

Often fast food/unhealthy

Do you have any specific dietary needs or goals?

Yes

If yes, please specify:

How much water do you drink on an average day?

Less than 1L

1-2L

More than 2L

Don't know

How many hours of sleep do you get on a typical night?

Do you feel rested upon waking?

Yes

What self-care practices are part of your routine to maintain or improve your health and wellness? (e.g., meditation, reading, spending time in nature)

How often do you engage in these self-care activities?

Daily

Weekly

Monthly

Rarely

Are there any physical health challenges or concerns you are currently facing?

Yes

If yes, please specify:

Do you have any specific health goals you are working towards?

Yes

If yes, please describe your goals and any steps you're taking to achieve them:

Career

What is your current occupation?

Are you happy in your current role?

Yes

Meh

Why you are happy in your current role?

Why are you unhappy in your current role?

What does Meh mean to you? And, please tell me why your job is meh.

If you could wave a magic wand, what would you be doing?

How does your current occupation influence your mindset towards work and personal growth?

Additional Information

Are there any specific techniques or approaches you are interested in exploring during our sessions?

Mindfulness practices

Goal-setting strategies

Stress management techniques

Other

If other, please specify:

Is there anything else you would like to share that can help me better understand your needs and how I can assist you?

Schedule Your Session

Being marvelous and being brave means you’re willing to believe in the wonder of who you are and take the risks you need to take to Bloom Breathe BE Be authentically YOU Break the mold Expand Evolve Flourish Grow Heal Fail Learn Live Thrive Transform Triumph Trust Succeed .