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What is your Gender Identity?

Male

Transfeminine

I don't know

Female

Transmasculine

Prefer not to say

Non-binary

Agender

Other

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LGBTQ+ Specialist?




Would you like to be matched

with a therapist who

specializes in LGBTQ+ issues?
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Help us match you to the right Coach!

Please fill out this short questionnaire to provide some background information about you and the issues you'd like to deal with in Coaching. It would help us match you with the most suitable Coach for you. Your answers will also give this coach a good starting point in getting to know you.


Mental/Emotional Intelligence

Financial

Physical/Nutrition

Spiritual

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What are your pronouns?






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Sleep Issues

Over the past 2 weeks, how often have you been bothered by any of the following problems:

 



Trouble falling asleep, staying asleep or sleeping too much.

Not At All

Several Days

More Than Half The Days

Nearly Every Day

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Have you ever been in coaching before?

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What led you to consider coaching today?

Please click on the "Next Step" button below after you make your selection. Select as many as needed.

I have been feeling unfulfilled

I cannot find purpose and meaning in my life

I want to gain self confidence

I struggle with building or maintaining relationships

I want to improve myself, but I do not know where to start

I am grieving

My mood is interfering with my job/personal life/school performance

I have experienced a roadblock, negative self talk and negative emotions

Recommended to me (family, friend, colleague)

I feel anxious or overwhelmed

I need to talk through a specific challenge

Just Exploring

Other

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What are your expectations from your Coach?

A Coach that . . . 

Listens

Challenges my beliefs

Proactively checks in with me

Helps me explore options

Assigns me homework

Other

Teaches me new skills

Guides me to set goals

I don’t know

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Physical Health

How would you rate your current physical health?



Good

Fair

Poor

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Eating Habits

How would you rate your

current eating habits?




Good

Fair

Poor

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Motivation

Over the past 2 weeks, how often have you been bothered by any of the following problems:

 


Little interest or pleasure doing things.



Feeling down, unmotivated, hopeless.

Not At All

Several Days

More Than Half The Days

Nearly Every Day

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What is your relationship status?

Single

Divorced

In a relationship

Widowed

Married

Other

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Depression

Over the past 2 weeks, how often have you been bothered by any of the following problems:

 


Feeling down, unmotivated, hopeless.

Not At All

Several Days

More Than Half The Days

Nearly Every Day

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Affect

Over the past 2 weeks, how often have you been bothered by any of the following problems:


 

Moving or speaking so slowly that


other people could have noticed?



Or the opposite - being so fidgety or restless that you have


been moving around a lot more than usual.

Not At All

Several Days

More Than Half The Days

Nearly Every Day

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Energy Levels

Over the past 2 weeks, how oftehave you been bothered by any of the following problems:

 


Feeling tired or having little energy

Not At All

Several Days

More Than Half The Days

Nearly Every Day

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Appetite

Over the past 2 weeks, how often have you been bothered by any of the following problems:


 

Poor appetite or overeating.

Not At All

Several Days

More Than Half The Days

Nearly Every Day

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Negativity

Over the past 2 weeks, how often have you been bothered by any of the following problems:

 

 

  • Feeling negative emotions or engaging in negative self talks

Not At All

Several Days

More Than Half The Days

Nearly Every Day

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Concentration

Over the past 2 weeks, how often have you been bothered by any of the following problems:

 



 Trouble concentrating on things, such as reading the newspaper or watching television.

Not At All

Several Days

More Than Half The Days

Nearly Every Day

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Level of Difficulty

If you have experienced these issues over the past two weeks, how difficult have these problems made it for you to do your work, take care of things at home, or work, or get along with other people?


Not Difficult At All

Somewhat Difficult

Very Difficult

Extremely Difficult

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Employment

Are you currently employed?
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Intimacy

Do you have any problems

or worries about intimacy?
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Alcohol

How often do you

drink alcohol?
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Anxiety

Are you currently experiencing

anxiety or panic attacks?
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Finances

How would you rate your

current financial status?



Good

Fair

Poor

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Comfort with Self

How comfortable are


you with your identity?

Not At All

A Little Comfortable

Somewhat Comfortable

Very Comfortable

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LGBTQ+ Coach





Do you prefer to be matched

with a therapist who is part of the

LGBTQ+ community themself?
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Communication

How do you prefer to


communicate with your Coach?


Mostly via messaging

Mostly via phone or video sessions

Not sure yet (decide later)

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About

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How old are you?








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How do you identify?

Straight

Questioning

Gay

Queer

Lesbian

Asexual

Bi/Pan

I don't know

Prefer not to say

Other

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Are there any specific preferences for your Coach?

Please click on the "Next Step" button below after you make your selection. You may select more than one answer.
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Who referred you to Moments Away?

Podcast

Friend or family

Google Search

Social Media Post

Tik Tok

Twitch

YouTube

other

Other

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Here are the Coaches we think would be a good fit for you!

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James Benton Personal Coaching

Josephine Darakjy Personal Coach

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