For New Mijas

Employer Paid Coaching Package Signup

Nice To Meet You, Mija!

Once you submit this form, an invoice will be sent to your employer and you will receive a link to schedule your coaching sessions. If you have any questions about the process, feel free to reach out—we’re here to support you every step of the way.

Step 1 of 4

This field is for validation purposes and should be left unchanged.

Choose Your Coaching Package

Duration

About You

Name(Required)

First Last

Today's Date(Required)

Birth Date(Required)

Facebook Name (if different than above)

Personal Email(Required)

Mobile Phone/Texting(Required)

Mailing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer Information

Business Name(Required)

Contact Email For Payment(Required)

Business Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Questionnaire

Are you in a primary relationship?(Required)

Are you in a primary relationship? If yes, list the name, length of relationship, degree of satisfaction on a scale of 1-10.(Required)

Have you ever been in therapy?(Required)

Have you ever been in therapy? If yes, on a scale of 1-10 (10 being the best) how would you rate your experience?(Required)

Are you currently on any medications for anxiety or depression? If not, have you ever been? Please explain.(Required)

What are the most important personal or professional development training/classes that you’ve had? What made this training important?(Required)

List 5 alternate lives that you would love to live. Don’t limit yourself by time or form, you can choose non-human forms.(Required)

Which two people, alive or dead, famous or unknown inspire you? Cite specific qualities that you admire.(Required)

What life experiences have alcohol/substances played a part past or present. Consider your relationship with alcohol, parents, extended family, spouse.(Required)

If you had a life purpose, what would it be?(Required)

What is the source of your greatest pain?(Required)

What are your spiritual or religious beliefs?(Required)

Have you ever received guidance from something, perhaps a source of wisdom beyond this realm? If yes explain.(Required)

If you could go back to your 7 year old Self, what does that person need to hear today?(Required)

What are your three main goals you have for coaching?(Required)

If you had to pick 1 thing that would make coaching worthwhile for you, what would that be?(Required)

What do you feel your biggest obstacles might be in getting you to your coaching goal?(Required)

What haven’t you shared that you believe is important to your growth?(Required)

Have you ever not finished something you started? If yes what got in your way?If not what kept you going?(Required)

What will you need to commit to stop doing so that you can make progress on your goals?(Required)

What do you need to commit to doing so you can make progress on your goals?(Required)

If you start to disengage or not show up for sessions, how would you like me to respond?(Required)

How do you want people to remember you?(Required)

Write yourself a reminder note here, that you can come back to during your commitment if fears, or doubts start to creep in. You know, a “kick in the butt” one.(Required)

What do you want to get out of coaching?(Required)

If you got that, what would you have?(Required)

Coaching Agreement

Signature(Required)

Date(Required)

CAPTCHA

For New Mijas

Employer Paid Coaching Package Signup

Nice To Meet You, Mija!

Choose Your Coaching Package

About You

Employer Information

Questionnaire

Coaching Agreement

Subscribe To Mija Moments Newsletter

Join the Mija community on Facebook

About Us & In Service

Community & Resources

Website Created By: