Personal Profile Coaching for Mind-Body Balance Please fill out and submit the following brief personal profile questionnaire at least 2 days prior to your scheduled coaching session or intro. Section 1: Contact InformationName First Last Today's Date MM slash DD slash YYYY Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Daytime Phone(Please give best phone #(s) to contact you.)Cell PhoneEvening PhoneEmail* Emergency InformationRelationship*Please SelectMotherFatherGrandmotherGrandmother (Maternal)Grandmother (Paternal)SisterBrotherSpouseChildGrandchildOtherDo not have an emergency contact Do not have an emergency contact Phone*Name* First Last Section 2: Vital StatisticsAgeDate of Birth MM slash DD slash YYYY Marital status Single Married Divorced Separated Widowed Genetic Sex* Female Male GenderPreferred pronounsEthnicityRaceWhat is your occupation?Number of childrenIf you have children, please list their names and ages:Have you been in thearapy or counseling in the past? Yes No Are you currently in therapy or counseling? Yes No If yes, since what date and how often?Have you ever been treated or hospitalized for a mental or emotional condition? Yes No Not Sure Are you taking any medications for mood stabilization or other mental or emotional health reasons? Yes No If yes, please list name and dosage of each:Have you ever been diagnosed with depression? Yes No Do you now have, or have you had in the past year, suicidal thoughts?Are you prone to bouts of anger?How would you describe your state of mind over the past 3 months? Overall good Overall not good If not good, please describe below:Do you tend to have a pessimistic outlook or depressive personality? Yes No Not sure Others might agree Do you have any physical health conditions that could make a day-long coaching session difficult for you? Yes No Possibly If yes or possibly, please describe below:On a scale of 1 to 10, please rate the likelihood you feel the coaching will bring you your desired results. Please elaborate.I understand that giving feedback on the survey forms provided or by email is important to the coaching process and I agree to fill out the various feedback questionnaires as requested.* I agree I disagree Please enter your Skype address here (important):Please enter your Skype address here (important):First of all, even if you already have skype on your computer, please go to skype.com and download the latest version. (Otherwise we will be unable to do three-way video with you. There are no further requirements for you for three-way video.) To find out your skype address, provided you already have one, please do the following: On a MAC: Open up your skype application. Go to the “File” drop-down menu, then choose “Edit Profile”. Your skype address will then be beneath your name at the top. On a PC: Open skype application Go to the Skype drop-down menu, choose “Profile”, then “Edit Profile”. If you don't have a skype account, go to www.skype.com and download the latest version onto your computer. Then kindly email us your newly chosen skype address at least 3 days prior to your consultation.
