360 LC Peer Mentor Coaching Orientation

Part 2: Client Questionnaire

Welcome to your transformative journey! Complete this questionnaire to begin your peer life coaching program.
Please ensure payment is completed in the application section before proceeding.



 

Section 1: The Past – Shadows, History, and Foundations

This section helps you explore formative life experiences, past beliefs, and unresolved emotions
that may still impact your life today.

Past Life Experiences











Emotional Health (Past Influences)









Education and Career (Historical Reflection)





Relationship History




Spiritual History







Section 2: The Present – Self-Awareness, Emotions, and Lifestyle

This section focuses on your current mindset, emotional state, health, and the relationships that shape your everyday experience.

Current Emotional and Mental State













Current Physical Health and Wellness











Present Beliefs and Lifestyle










Relationships and Environment









Section 3: The Future – Vision, Goals, and Intentional Growth

This section helps you envision who you want to become, what goals matter most, and how you intend to move forward with intention and clarity.

Future Vision and Self-Concept









Career and Purpose Goals








Personal Development and Motivation










Unaccomplished Goal Reflection







Section 1: The Past – Shadows, History, and Foundations

Welcome to Your Coaching Journey

As your Life Coach, our role is to act as a catalyst—guiding you from where you are now to where you aspire to be.
We focus on the present and future while helping you recognize any lingering energy from the past that may still be affecting you.

⚠️ Please note: If you are currently dealing with unresolved trauma, we will kindly refer you to a licensed therapist,
as that level of support is outside our coaching scope.

About This Form

This intake form is your first step in the coaching process. It’s designed to help both you and your coach gain clarity about your
current mindset, goals, and desires. The questions are reflective and may require some thoughtful consideration.
You only need to complete the sections that are relevant to you. If a section doesn’t apply, simply write “N/A.”

  • Answer each question as completely and honestly as possible.
  • If a question doesn’t apply to you, write “N/A.”
  • Use this opportunity to reflect on your journey, organize your thoughts, and define your goals.
  • Once completed, proceed to checkout to finalize your booking.

Past Life Experiences











Emotional Health (Past Influences)









Education and Career (Historical Reflection)





Relationship History




Spiritual History





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GET IN TOUCH

Company number: 1 (561) 389-5974

Email: BestPart@360lifechanges.info 

Address:
12361 Hagen Ranch Rd
Suite 503 PMB 1057
Boynton Beach, FL 33437
United States