Questionnaire – Coach Steph

I'm excited to work with you! PLease fill out this questionnaire before we get started.

Name

DOB

Address

Phone Number

Best Way to Communicate:

Email Text

In a few sentences share your diagnosis story with dates:

Do you have other health concerns outside of your cancer diagnosis (please be as specific as you can):

Which side is your breast cancer on (or where did it start if it is metastatic)?

Are you working with an oncologist:

Are you working with an integrative practitioner:

Who else is on your “healing team”:

Do you feel like you have a good support system in place?

How do you feel about your overall health?

What areas of health do you feel like you need to improve the most?

What areas of health do you feel like you are a Rockstar?

Do you understand what taking an integrative approach to your healing is?

What would you like most to get out of our time together?

Do you have any spiritual practices?

Are you physically active?

How can I serve you best in this place?

What would be your #1 goal from completing our Group Coaching Program?