Form Fill Coaching | It's A Nu Dai Community Lounge

Full Name*

Preferred Name (if different):

Pronouns

Email Address*

Phone Number:*

Preferred Method of Contact: (Email, Phone, Video Call, Other)*

How did you hear about us?*

What type of coaching are you interested in?*

🌿 One-on-One Wellness Coaching

🌱 3-Month 1:1 Wellness Coaching Package

💼 Workplace Wellness Coaching (for employees or leadership teams)

Other

If other, please specify

What areas of your life do you need support with? (Select all that apply)*

⚖️ Work-life balance

🌈 2SLGBTQIA+ identity, self-acceptance, or relationships

❤️ Couples coaching & relationship guidance

🌟 Youth coaching (teen/young adult support)

😰 Stress & anxiety management

🏢 Workplace wellness (burnout, productivity, toxic work culture)

Other

If other, please specify

What are your biggest challenges in this area?*

On a scale of 1-10, how would you rate your current well-being? (1 = Struggling, 10 = Thriving)

How would you describe your current work-life balance? (if applicable)

What workplace challenges are you facing? (e.g., burnout, job dissatisfaction, toxic environment, if applicable)

How does stress and anxiety impact your daily life?

What coping strategies do you currently use? (If any)

Do you have any current mental health concerns that you’d like to address in coaching?*

If seeking couples coaching, what are your key concerns in your relationship?*

Are you looking for support in self-identity, self-acceptance, or personal development?

What days/times work best for your coaching sessions?*

How committed are you to making changes in your life right now? (1 = Not Ready, 10 = 100% Committed)*

What would success in your wellness journey look like for you?

Welcome!