Private Coaching with Chelsea Dinen
Thank you for your interest in working together one-on-one.

This workbook serves as an application to begin coaching with Chelsea. Please fill this out openly & honestly. Upon reviewing your application, I will email you to book your complimentary introductory session to answer any questions and discuss what you would love to receive support with.

All information will be kept confidential.
What is your full name? *

What name would you like to be called? *

How did you find me? *

Examples: I found your YouTube video on simplifying your life, I discovered your Instagram, my friend referred me to you, etc.
What is your email address? *

What is your Skype username or email address? *

What is your mailing address? *

When is your birthday? *

Marital Status: *

As your coach, it is essential for me to be aware of past/present addictions, events, medications, treatments, and/or ways of thinking that may influence your life now. (i.e. Are you in a 12-step program? In therapy? Do you have a learning disability?) Please list any information below: *

Are you willing to be completely open and honest? *

If you experience realistic growth in the next month, what would that look like for you? *

What has been holding you back? *

The blocks, the challenges, the fears that have been keeping you from what you want.
How has living at this current level impacted you negatively? *

What currently helps you shift your energy from negative to positive? *

Examples: Meditation, Going for a run, Writing in my journal, Prayer, etc.
Are you willing to make a significant investment in yourself? *

Coaching requires a significant investment in your time, energy, and money. Are you ready to make this commitment to yourself?
How will you know that you're receiving value from working with me? *

In other words, what outcomes will make this investment in coaching worth it to you?
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