WAYFINDING WITH WRITING ROADS

The Intake Form

Name

First Last

Phone

Your birthday

Which aspects of your life are most energizing or supportive?

Which aspects of your life are most frustrating or draining?

Who’s on your personal support squad?

Name

Relationship

What, if any, mental health or other coaching support are you currently receiving?

List three specific things you’re hoping to get from this coaching engagement.

What are a few challenges you’re currently facing?

What’s your greatest fear?

If you could wave a magic wand and change anything in your life, what would it be?

If you had no responsibilities and all the money and unlimited freedom, what would you do, who would you be?

How do you usually feel in your everyday life? How do you want to feel?

Is there anything else you want me to know?

Emergency Contact Information

Emergency Contact Name

First Last

Emergency Contact Email

Emergency Contact Phone

This field is for validation purposes and should be left unchanged.

Julie Roads’ services and products are not intended to diagnose, treat or cure any psychological or medical conditions. Her website, social media feeds and products may include information and instruction relating to psychological, emotional, and mental wellness, EFT tapping, coaching, meditation, energy therapy, breathwork and yoga and our website and products relate to these topics for informational purposes only. Nothing contained on the website or products offered by Julie Roads are to be construed as any form of medical advice or diagnosis. © 2023 by Writing Roads | Site Designed by Simply Styled Sites