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.
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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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