New Client History and Reflections Questionnaire Name First Last Email PhoneAddress 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 Date of Birth MM slash DD slash YYYY Gender IdentityOccupationIndicate Preferred Days for Private Coaching Sessions (Monday-Friday)How were you referred?What is your most pressing concern?When did this concern begin and how does it affect you and your life?Describe any significant events which occurred at the time or since then, which may relate to the development or maintenance of this concern.How would you estimate the severity of this concern?Mild, moderate, severe, or very severeAre you having difficulties/stressors in your current job as a result of these concerns? If so, please describe.What do you hope to accomplish by committing to coaching with Kori?Have you used a system like this or engaged in coaching/consulting/therapy before or received any prior support for your concerns?Please give dates, reasons for seeking support, and type of support. Behaviors: Check any of the following that apply to you which feel like they are affecting your quality of life.(Required) Emotional Overeating Sleep disturbances Withdrawal Overwork Burnout Avoidance Binge Eating Purging or other compensatory measures post-meal Lack of motivation Procrastination Body image obsession Anxiety Low self-confidence Fear of food Inability to relax Low emotion regulation Don’t handle pressure well Too much caffeine Impulsivity Overwhelm Feelings: Check any of the following that apply to you, which feel like they are affecting your quality of life.(Required) Anger Confusion Content Guilt Energetic Restless Depressed Fear Relaxed Hopeful Tense Annoyed Regret Excited Lonely Panic Jealous Helpless Stuck Sad Optimistic Frustrated Sensations: Check any of the following physical experiences that apply to you, which feel like they are affecting your quality of life.(Required) Headaches Stomachaches Gastrointestinal Distress Skin issues Dizziness Tics Brain Fog Wired but Tired Fatigue Muscle Cramps Sexual Disturbances Low libido Hot flashes Mood swings Significant weight changes up or down Irritability Pregnancy Do you have any allergies? If yes, please list them below:Do you have any concerns specifically about your physical health?Past and present medical care (major medical, illnesses, surgeries, accidents, etc):Please list medicines or supplements you are currently taking or have taken during the past 6 months (include any medicines that were prescribed, taken over the counter, or illicit):If appropriate, have you been or are you amenorrhoeic (lacking your period)? Have you experienced or are you experiencing currently an irregular menstrual cycle, changes in length or intensity of bleed?Have you been hospitalized or attended inpatient, partial IP, or outpatient treatment for disordered eating or any other mental health conditions (i.e., drug/alcohol use/abuse, AA, NA, treatment)?Are you currently dieting or restricting food, following a certain dietary plan or regimen, or attempting to meet certain body ideals? Is your eating impacted by what you see on the bodyweight scale?Please describe what a typical day of eating and movement looks like for you.Significant others that you will mention who are important in your life / your support system, living or deceased.Please include what type of support they provide for you.Please describe your childhood.Relationships with caregivers, relocations, sense of safety, etc.If your parents divorced, please list your age at the time and describe how it affected you then, as well as how you see it affecting you now.Do you feel your use of technology (i.e, Youtube, FB, IG, Gaming, TikTok, Texting, etc.) is balanced and healthy or could it use improvement?Do you have any spiritual or religious beliefs or practices that support you?What do you feel passionate about in life? What gives your life meaning?What are your deepest values?What would you like to contribute to the world and how do you plan to do that? If you have a formal personal/professional mission and vision, please share that.What have you contributed or accomplished already?What other major accomplishments brought you a sense of fulfillment? Share any that you’d like me to know about.What do you consider your character strengths? I will ask you to take a strengths and values assessment), but please share your personal insights.Tell me about a time when you overcame a challenge or met an important goal by being at your best.How would you rate your commitment to approaching wellbeing in your life differently? Use a 10-point scale at this time, with 1 indicating not at all and 10 totally committed.What prevents you from feeling grounded, present, and intentional?Do you have any personal practices for managing stress?Please share frequency and duration.What energizes you? Puts you in a positive mood where you feel capable, calm, and clear?What are you learning and accepting about yourself at present? Your growing edge?Intimate Relationships 1- Not at all 2 3 4 5- Very Satisfied Consider the following aspects of your life. How would you rate them in terms of your current satisfaction? 5= totally satisfied; 1=not at all satisfiedPlay, Fun, & Leisure 1- Not at all 2 3 4 5- Very Satisfied Consider the following aspects of your life. How would you rate them in terms of your current satisfaction? 5= totally satisfied; 1=not at all satisfiedFamily & Friendships 1- Not at all 2 3 4 5- Very Satisfied Consider the following aspects of your life. How would you rate them in terms of your current satisfaction? 5= totally satisfied; 1=not at all satisfiedWork, Career, or Business 1- Not at all 2 3 4 5- Very Satisfied Consider the following aspects of your life. How would you rate them in terms of your current satisfaction? 5= totally satisfied; 1=not at all satisfiedFinances 1- Not at all 2 3 4 5- Very Satisfied Consider the following aspects of your life. How would you rate them in terms of your current satisfaction? 5= totally satisfied; 1=not at all satisfiedSelf-Care(Sleep, Attitude, Nutrition, Body Image, Movement) 1- Not at all 2 3 4 5- Very Satisfied Consider the following aspects of your life. How would you rate them in terms of your current satisfaction? 5= totally satisfied; 1=not at all satisfiedSelf-Development (Learning, growth, formal or informal) 1- Not at all 2 3 4 5- Very Satisfied Consider the following aspects of your life. How would you rate them in terms of your current satisfaction? 5= totally satisfied; 1=not at all satisfiedEnvironments (home, work, or other) 1- Not at all 2 3 4 5- Very Satisfied Consider the following aspects of your life. How would you rate them in terms of your current satisfaction? 5= totally satisfied; 1=not at all satisfiedMeaning and Purpose (spirituality, wholeness, truth, self-worth) 1- Not at all 2 3 4 5- Very Satisfied Consider the following aspects of your life. How would you rate them in terms of your current satisfaction? 5= totally satisfied; 1=not at all satisfiedWhich of the above would you most like coaching to address?What are two or three immediate changes you’d like to make that our work together could address to help you get off to a good start?Anything else you’d like me to know about you or your goals?