Your information is confidential and will only be read by Bryan Arndt (aka Dr. Bryan / Reverend Dr. Bryan Arndt), a certified Life Coach, Spiritual Counsellor, and Pastoral Care practitioner. You will receive an acknowledgement of your submission, therefore use a private email address that only you have access to. This questionnaire requires concentration and it will take at least fifteen minutes, if not more, to complete. Please allow yourself sufficient time to be thorough and accurate.
Your initial 30 minute consultation, where we discuss the confidential details of your submitted questionnaire is Free.
Your first and last name
Your email address
Your phone number
Preferred method of contact
Your full mailing address (Street, City, Province/State, Postal/Zip Code, Country)
Desired method for sessions
Method of payment
Please check any of the following health conditions that apply:
Are you currently under the care of a medical doctor? If yes, please describe why.
Are you currently taking prescription medication? If yes, name the drug(s) and the medical condition(s) for which you have been diagnosed.
Are you now, or have you ever been treated by a mental health professional? If yes, please describe.
Regarding Coaching / Counselling: Please answer the following questions honestly and briefly, yet thoroughly. Take your time and remember, this questionnaire is confidential.
I am interested in:
1. What is your primary reason for wanting Coaching / Counselling?
2. What benefits will you gain once your desired objective is reached?
3. What are you expecting to happen when using a Life Coach / Spiritual Counsellor?
4. What is the most empowering and helpful thing I can do for you during our sessions?
5. How will you know your session is successful?
6. Please list three things you like best about you - right now.
7. What are you most passionate about?
8. What do you like most about your life right now?
9. What do you like least about your life right now?
10. Where do you see you and your life being one year from now?
11. In what area/areas would you like to grow and experience positive change within yourself?
12. What one thing could you do in your personal and/or professional life that if you did on a regular basis, it would make a tremendous difference in your life?
13. Would those who know you best say that you are more outspoken or more reserved? On a scale from 1 to 10 with 1 being very reserved and 10 being very outspoken, which number do you think they would pick?
14. Would those who know you best say that you are more emotional or logical? On a scale from 1 to 10, with 1 being very emotional and 10 being very logical, which number do you think they would pick?
15. On a scale between 1 (lowest) and 10 (highest), where would you currently rate your self-esteem?
16. What do you believe is holding you back or blocking you?
17. What benefits do you gain by NOT reaching your objectives?
18. What fear/fears do you have concerning moving forward with your objectives?
19. What is the most critical thing/things you say to your whole self?
Have you ever had Life Coaching before?
Have you ever had Spiritual Counselling before?
Feel free to add any additional comments you have here:
Your commitment and your agreement:
1. I understand that I must be fully committed to making positive changes in myself to see beneficial results. To this end, I authorize this practice to engage me in coaching and I commit to following the mutually-agreed upon actions given me during my sessions, and to keep all scheduled appointments.
2. I understand that staff members of this practice are not provincial or state licensed medical or mental healthcare professionals and do not prescribe drugs, diagnose medical/mental conditions, or provide therapeutic treatment or advice for such conditions. Nothing contained in any information provided by the staff or this practice, either verbally or in print, is intended to constitute or be construed as professional medical or psychotherapeutic advice for diagnosis or treatment. The methods used by this practice are transpersonal coaching, general personal growth and empowerment techniques, positive suggestion, guided imagery, visualization, and/or relaxation techniques.
3. I understand that staff members of this practice are ethically and legally bound to protect the confidentiality of our communications. I understand that you will only release information about our work to others with my written permission or in response to a court order. I understand that there are some situations in which you are legally obligated to breach confidentiality in order to protect me or others from harm. I understand that if you receive information that indicates a child, elderly, or disabled person is being abused, you must report that to the appropriate provincial or state agency. I also understand that if I become an imminent risk to myself or make threats of imminent violence against another, you are required to take protective actions by filing a report with local law enforcement.
4. I understand that the results of my sessions depend greatly upon my own serious participation and, therefore, this practice cannot offer any guarantee of the success of my sessions. I am aware, however, that this practice will do everything reasonably possible to ensure my success.
5. I agree to pay for all services when rendered (unless prior arrangements have been agreed upon). I understand that, except for emergencies, 24 hours notice must be given when cancelling or rescheduling an appointment otherwise I agree to pay for the missed appointment.
I have read, understand, and I fully accept all five of the Commitment and Agreement clauses:
Make a free website with Yola