Your 1st Session for $20 | ME Wellness Coaching

First name

Last name

Email

Phone

Have you ever worked with a coach or therapist before?

Yes

No

If yes, what did you find most helpful about your experience?

Are you currently under care of a mental health or medical professional?

Yes

No

If yes, please describe:

Currently taking medications related to mental/emotional health?

Yes

No

If yes, please describe:

If Other was selected, what would you like to focus on?

On a scale of 1–10, rate the following (1 = very low, 10 = very strong):

Emotional well-being

Physical energy:

Stress level:

Social support:

How do you prefer feedback/support? (Check all that apply)

gentle encouragement

accountability

reflective

practical tools

Preferred session format:

virtual session

phone session

self study w/ email support

I understand that ME Wellness Coaching provides non-clinical, wellness-based coaching and does not provide therapy or medical treatment. All information remains confidential except where there is risk of harm. I am responsible for my well-being and decisions during and after coaching.

I agree with the above statement.

Thank you for completing this form. Your openness helps us tailor your coaching experience to best support your growth and well-being. We will send our recommendations to you shortly. — ME Wellness Coaching

Welcome, We're Glad You're Here.

Get your 1st Coaching Session for $20.