Name:
Street Address:
City and State:
Country:
Cell #:
Email:
DOB:
Occupation:
How did you hear about me (if you found me in Google, what did you search for)?
Please describe your overall health:
Have you ever been diagnosed with, hospitalized or treated for a mental health condition? If so, please describe:
Do you have any problems with ADD/ADHD, addictions, depression or anxiety? If so, please describe:
Are you currently undergoing therapy? If so, please describe:
Are you taking any medications? If so, please describe:
What do you do for fun?
What are you great at (work, hobbies)?
What do you believe you have to contribute to the world?
Is there a secret passion in your life? If so, what is it?
If you knew you could not fail, what would you attempt to do?
How would you rate your overall life satisfaction from 1-10? What’s missing in order for it to be a 10?
What are your top three nagging fears, frustrations, doubts, or problems?
What's the one thing that’s most likely to wake you up in the middle of the night in a cold sweat?
What are your specific goals for our sessions? Which goal is most important to you?
What will you gain from achieving these goals?
How would you know for sure that you have achieved your goals?
How long do you expect it to take to reach these goals?
Would there be any downside to reaching your goals?
Do you feel that the benefits will be worth the effort?
On a scale of 1-10, how important is it for you to finally achieve these goals?
Do you know exactly what you need to do to achieve what you want?
Do you have anyone in your life who is helping you in these areas?
Describe what your perfect life would look like:
What dreams do you have? Have you given up on any them?
What part of your life, career, or relationship is working best right now?
What are the obstacles/challenges that are keeping you from living the life you truly want?
What do you think has stopped you in the past from overcoming these obstacles?
Why do you feel you’re a good candidate for my coaching process?
Is there anything else you’d like me to know?
Please check the box if you agree to the terms, then click "send." CLIENT CONSENT & RELEASE: I am over the age of 18 years old and hereby agree, voluntarily and freely, to receive information from Jay Cataldo. I understand that Jay Cataldo is not a licensed health care practitioner and that the information I will be receiving is not legal, therapeutic or personal advice and can not be considered as such. This information cannot replace or substitute for the services of trained professionals in any field including, but not limited to, psychological, financial, medical or legal matters. I understand that I should consult a medical professional concerning any symptoms that may require medical attention. I also promise to disclose any prior or existing or mental health condition to Jay Cataldo. I further release both Jay Cataldo and Relate Right Inc. from being held liable in any manner whatsoever stemming from my use of the information I will be learning, including, but not limited to, economic loss, injury, illness, harmful effects, emotional distress or death. I assume full responsibility for the consequences of my own decisions and actions. I declare that I have read this consent and release, and that I fully understand and agree to its terms.
