Self-Sabotage Coaching Form

Section 1. | Begin Here

Please select at least one option.

Name *

What is your age range?

Email address *

Height (in feet and inches please)

Weight (pounds please)

Marital Status *

Previous marital history

Number of children *

Ages of children and first names (in case they are mentioned in our conversations):

Current occupation *

Past Occupations (from 10 years old onward): *

Gender at birth

Phone numbers (cell and landline...just in case we need to use these methods to communicate):

Alternate email address:

Current Address

Time zone (note: Place of birth address (is place of birth time zone different than where you currently live):

Can I send you a ZOOM link or other virtual meeting link 15 minutes prior to our appointment? We use virtual meeting rooms to conduct our sessions over long distance. Can I also send a virtual meeting link 1-2 hours before our appointment, just to remind you that we're meeting. Facebook profile (full URL): *

Please select at least one option.

Yes

No

Facebook profile (full URL)

Instagram profile (full URL)

Next of kin name *

Next of kin email *

Next of kin phone number

What is the primary reason you've contacted me and in what area (s) do you need improvement? *

Tell me your story? *

Are there any particular and/or pressing issues you would like addressed, during the self-sabotage coaching session?

Unload a bit about what's eating at you about life in general, yourself or your historical/current situation...I have time, let it out, everything is confidential.

Please select at least one option.

Section 2. Health | You're really moving yourself in the right direction - Congratulations

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List all medications taken over the last 10 years - please list with full names of medications *

How many vaccines have you taken over the last 20 years? *

Do you have any diagnosed diseases - if so which ones?

Have you ever taken an antidepressant medication - if so, which ones and over what length of time?

- Please list all your surgeries over your entire lifetime, including elective and cosmetic surgeries *

How many times have you been into the medical system over the last 5 years and for what issues? *

Please list the aches and pains you have over your entire body (where do you hurt) *

Have you ever visited a Chinese medical doctor and what was the diagnosis tabled (which organ system(s) needed support):

Have you invested in any alternative health practitioners (chiropractors, energy healers, hypnotherapists etc.)

Do you use over the counter painkillers, allergy medicines, any over the counter medicine (if so which ones and how frequently)?

Have you done any cleanses or fasting in your life and if so, which ones and when were they executed?

Do you have any allergies to food or to anything else. If so, please list:

Do you have acne or disrupted/discolored skin?

Do you have itchy skin or itchy areas of your body?

Do you wear corrective glasses or contacts?

Do you have any mercury teeth fillings. If so, how many? They are gray or black? Do you remember the ages when you got them?

Do you have any other teeth fillings made of composite, usually white? Do you remember the ages when you got them?

Do you have any root canals? If so, do you know when they were done and how many you have?

What toothpaste do you use?

Does your toothpaste have fluoride or carrageenan in it (please check)?

Please select at least one option.

Yes

No

Is the water in your area fluoridated?

Do you exercise on a regular basis? *

Please select at least one option.

Yes

No

Please describe your exercise routine in full detail for the week if you do exercise.

Do you have any home equipment you no longer use in the home (if so, which pieces)?

How many diet programs have you tried over your lifetime?

Do you have any diet or healthy cookbooks in the house?

How many different gyms (or health studios) have you been a member of over the last 20 years?

What is the date in your history where you've been the heaviest you've been and what was your heaviest weight? List your heaviest weight and the time when you were steady around this weight.

Please describe your caffeine intake (coffee, energy drinks, teas, pre workout, chocolate, etc.) I need exact amounts of each taken in a week:

Do you frequently feel cold?

Please select at least one option.

Yes

No

What is the state of your finger/toenails and your hair (thin hair, ridges on nails, fungal infections, balding etc.)?

Do you use wireless internet on a laptop that sits on your lap?

Please select at least one option.

Yes

No

Do you hold your cell phone in your pocket or talk with the cell phone to your ear?

Please select at least one option.

Yes

No

Do you keep your cell phone within 3 feet of you for a good portion of the day?

Do you wear a Fitbit or iWatch?

Please select at least one option.

Yes

No

Do you wear wireless headphones or use any other wireless device?

Please select at least one option.

Yes

No

Do you work in an industry where there is lots of Wi-Fi exposure?

Please select at least one option.

Yes

No

Do you have Wi-Fi at your home (how close is the nearest router to your couch or your bed)?

Do you have Wi-Fi at your business (how close is the nearest router to your workstation)?

Do you have a SMART TV, which is wireless?

Please select at least one option.

Yes

No

Do you have a Wi-Fi measuring device?

Please select at least one option.

Yes

No

How many hours of Wi-Fi exposure per day do you get where you're within 5 feet of your computer, phone, laptop, or wireless router?

Do you have any baby monitors in the house?

Please select at least one option.

Yes

No

Do you live in an apartment complex where many Wi-Fi signals are present?

Please select at least one option.

Yes

No

Do you have any new emerging marks on your skin or skin tags?

In the last 6 weeks what time are you going to bed?

In the last 6 weeks what time are you getting up?

Is your sleep interrupted at generally the same time nightly - if so what time?

Do you feel tired during the day at generally the same time - if so what time?

Do you watch pornography, if so, how frequently?

Do you play the lotto, use scratch and wins, or gamble? If you don't right now but did in the past, please describe when you did, what gambling method you used and how often you used that gambling method.

If you get up in the middle of the night frequently, click on this website: https://elanvital-coaching-staging.b12sites.com/body-clock. Then please name the regular time that you're being awakened at and maybe list the reason why you're thinking you're getting up at this time. The image below simply shows the timelines of organ stress that can wake us up (or make us tired) at different times of the day

Do you feel tired during the day at generally the same time?

If you work night shift please describe.

Do you watch TV or watch any screen before you go to bed?

If you do watch a screen before bed, how long is it watched for?

What do you watch before bed (certain shows, YouTube videos, etc.)?

Do you wear any blue light blocking glasses before sun up or after sun down?

Please select at least one option.

Yes

No

Name 5 TV series you've watched over the last 3 years

Name the last 5 movies you've watched on Netflix, in theatre, etc. After naming those movies, please list how long ago you've watched them

Do you drink coffee (if so, how many per day) what sizes and how many of each size and even the coffee shop where you get them)?

Do you smoke cigarettes (if so, how many per day)?

Do you drink any alcohol whatsoever (if so, how many ounces/beers or glasses of wine per day.... be accurate)? *

Do you currently use narcotics (if so, what do you use and what quantity per day....be accurate)?

If you don't use narcotics, alcohol, cigarettes, or coffee currently but did in the past, what ages did you use and what was the quantity used? *

Have you adopted any healthy habits over the last 5 years (please describe exactly what they were)?

What unhealthy habits do you still participate in?

If male, were you circumcised?

Please select at least one option.

Yes

No

If female, were you exposed to any genital cutting, common in certain cultures across the world?

Please select at least one option.

Yes

No

How much water do you drink daily and what brand do you consume?

Provide a 4-day diet log of everything you eat and drink in a day (including non food items like gum, medications, vaping, smoking, chewing tobacco etc.) - please also indicate if the food you consume is organic, biodynamic, humanely raised or non organic? PLEASE INCLUDE THE DIET LOG RIGHT HERE IN THE QUESTIONNAIRE AND NOT AS A SEPARATE ATTACHMENT

Please name all the personal care products you use daily and the brands?

Do you use a microwave to heat up or defrost your food (if you do provide the number of times you do it per day – the number would indicate the combined defrost and cooking situations)?

How long does it take for you to eat your meals and do you eat them with family, alone, sitting down, in a car or standing up?

Do you do any active relaxation (yoga, stretching, meditation, naps, massage, walking in nature, etc.)?

How many vacations do you take per year either alone or with your romantic partner?

Are you currently getting what you need on an emotional or sexual level inside your current relationship YES OR NO (please explain if you wish to describe)?

Please select at least one option.

Yes

No

Section 3. Personal History

Please select at least one option.

If you have any questions, you can always email me. I am always here for you. Feel free to express yourself here...

Did anything occur in your life that you consider traumatic (please describe if you wish)?

Did anything occur in your life that you hold guilt or shame about (please describe if you wish)?

Have you ever filed for bankruptcy (if you answered yes how many times and in what amount)?

Other than your home mortgage, do you have any credit card debt over $5000?

Please select at least one option.

Yes

No

Name all the clubs or associations you belong to and the groups you affiliate with (vegan, marathoner, Tough Mudder, Spartan racer, cancer survivor, charity organizer, church, reading group, Crossfitters, AA, war vet, etc.):

Do you attend religious services currently?

Did you attend religious services or Sunday school in your first 7 years of life (if so with what frequency)?

Name all the schools you attended in chronological order and denote if they were public or religious:

Do you play music on the radio in your car and if so, what sorts of stations do you listen to?

Do you find you're too busy and work too much at times?

Do you have any piercings or tattoos (please describe how many, what they are, which side of the body and location) (pictures are also good if you want to volunteer)?

Have your ever cut yourself or hurt yourself purposely?

Name your 3 best friends, their estimated weights, their occupations and their diseases or addictions:

Do you live in a lower, middle class or upper-class neighborhood?

Did any of your parents wear a crucifix around their neck or do you wear one?

Please select at least one option.

Yes

No

Section 4: Family Background - Mother and Father

Please select at least one option.

Thank you for continuing along your journey and exploring your issues, to understand your own behavior more fully. (If you don't have a father or mother, please use the person who filled those roles in your life)

Please select at least one option.

Did you move around often? How many houses did you live in as a child, locations and durations in each city/town are needed.

Were the areas wealthy, middle class or poverty stricken?

Please list everyone in your immediate family - with ages and first name and family titles (father, sister etc.). Please also include your own name and show where you fit in age wise within the family.

Please also list if you can if they are still with us and if not, when they passed away and from what issues/diseases. Thank you

Did your mother or father drink alcohol, smoke cigarettes, drink coffee, eat junk food/fast food or use narcotics weekly when you were a child?

Was their physical hitting or sexual abuse toward the children in the family home?

Did any of your parents or siblings have a criminal record when you were a child?

Were either your mother or father overweight (please list them by name and their weight, within 5-10lbs)?

Did your mother or father follow a structured exercise routine every week?

Please select at least one option.

Yes

No

What was/is the sexual orientation of both parents?

What was your mother's occupation in your childhood (please list all her sources of income/jobs for as long as you can remember up until present)?

What was your father's occupation in your childhood (please list all his sources of income/jobs for as long as you can remember up until present)?

Did your mother or father have any diagnosed diseases?

Did your mother or father take any medications?

What was the general routine in the family home of the parents (examples....Mom would take care of the kids, worked hard, drank coffee every morning, cooked for Dad, Dad left at 7 in the morning, got home, starting drinking beer and watching TV etc......Mom was medicated, I had to take care of my siblings, Dad was absent, etc.)?

Were you raised by one or both parents?

Please select at least one option.

Yes

No

If your parent(s) passed away or divorced when you were a child, when did it happen?

Describe how you felt when this occurred?

Is there anything hurtful or very impactful that either of your parents said or did to you, during your childhood (if so, what sticks out the most)?

Was the TV a regular "thing" to be on in your family home?

Please select at least one option.

Yes

No

If you were to synthesize the emotional "cloud" or "primary vibration" that was most dominant in your family home as a youngster and you had to use one word or phrase to describe it, what would it be (example...joyful, exciting, amazing, constantly supportive, critical, depressing, competitive, combative, etc.) (you can use several words and phrases if you wish)?

That's the end of this section. If you need to, take a break, and come back tomorrow. No rush. I am always here for you whenever you finish.

Please select at least one option.

Family Background – Siblings

Please select at least one option.

You are almost done. Thank you so much for doing the work and moving ahead. You're an amazing client. I look forward to working with you.

Please select at least one option.

How many siblings do you have?

Please list them by first name and age and place yourself in the list, in chronological order

Please describe the current marital status of each sibling

Please describe the marital history of each sibling:

Please describe the weight of each sibling and height (in feet and pounds)

Please describe any diseases they've been diagnosed with:

Are you aware if any of your siblings take medication (if so which medications and for what disorders or diseases)?

Did any sibling in your family try to commit suicide?

Please select at least one option.

What are their occupations?

What are their sexual orientations?

Do they have any addictions you may notice?

Do any of your siblings use alcohol, coffee, cigarettes, junk food or narcotics weekly?

Please select at least one option.

Yes

No

Do any of your siblings eat out at fast food restaurants?

Were you adopted?

Please select at least one option.

Yes

No

Were any of your siblings adopted?

Please select at least one option.

Yes

No

Final Section: Personal Growth, and Healing

Please select at least one option.

Here's the last section - thank you so much for doing the work and moving ahead. You're an amazing client. I look forward to working with you. Read the first 4 questions but don't answer them until you've completed the rest of this section

Please select at least one option.

1. What is your dream? (If you had $150 million in your bank account right now, what does your daily and yearly routine look like and what do you want to accomplish before you pass away?)

2.. What do you stand for? (What are your core values that you'll never negotiate, regardless of what's offered in return?)

3. What are you willing to change to improve your life?

4. Fill in the blanks. I AM X, Y AND Z.......creating X,Y and Z. My vision is X, Y and Z. Here's an example. My name is Jason Christoff. I'm healthy, logical, and constantly remembering. I'm creating educational courses, healthy living guidelines and manufacturing ever increasing opportunities for self-improvement and happiness in the now. My vision is a logical society, full of healthy independent thinkers, who are empowered to lead moral and ethical existences.

In order to clarify what your dream really is......list what you absolutely don't want with respect to health, wealth, relationships and positive self talk. (I want 4 separate declarations for each “don’t want” category). For example...I don't want to live pay cheque to pay cheque, or I don't want to stay in the cycle of failure based dieting or I don't want to date someone who needs me to take care of them or I don't want to always think negatively about my life and the direction it’s going in. All 4 categories must be addressed regarding what you don't want

Between the areas of health, wealth, relationships, or positive self talk........where do you think you're encountering the most resistance or active self-sabotage? If you're encountering self sabotage in another category altogether, please list that as well. You can give more than one area of self sabotage that needs re-programming.

Write down 4 phrases or words about both your mother and father, which describe something that drives you a little crazy about them or something you can't really deal with (4 for your mother and 4 for your father).

Now find your best friend or an ex romantic partner and ask them to do the same exercise for you. Do you see any similarities between your list and what others see in yourself? It's best to at least find a friend if you can but sometimes, if you're honest with yourself, you can answer this one yourself. (Example - mother - judging - nothing is ever good enough - can't take a break and not feel guilty - no adult-based emotional stability and now.... father - addicted - not present - childlike - no spiritual development.)

What is your dream with respect to wealth? Tell me what it sounds like? What does it taste like? What does it feel like? What does it look like? You must answer each question with 4 separate statements. (For example, maybe your wealth dream is to stop getting up with an alarm clock and maybe it sounds like complete silence at your new country home; maybe it tastes like an amazing meal from a famous in house chef you hired for a Valentine's day dinner; maybe it feels like you are holding hands with your partner in first class, giggling because the food is so good.) Sounds, taste, feel and look...all need answers.

What is your dream with respect to health? Tell me what it sounds like. What does it taste like? What does it feel like? You must answer each question with 4 separate statements. (for example, maybe your health dream is to walk the beach in a regular bathing suit or to stand naked proudly in front of your partner.....maybe it sounds like a compliment from a friend you haven't seen in 2 years; maybe it tastes like a healthy meal at an organic restaurant and maybe it feels like a new outfit that finally fits). Sounds, taste, feel and look...all need answers.

What is your dream with respect to relationships? Tell me what it sounds like. What does it taste like? What does it feel like? You must answer each question with 4 separate statements. (for example, maybe your relationship dream is to receive as much love as you put forward and it may sound like an "I love you" every time you leave the house, maybe it tastes like your partner's amazing new lip moisturizer as they give you a passionate kiss out of nowhere...which leaves you gasping for air, maybe it feels like complete trust in the fact that your partner loves you fully, heart and soul and you know they have your back no matter what). Sounds, taste, feel and look like...all need answers.

What is your dream with respect to positive self-talk? Tell me what it sounds like? What does it taste like? What does it feel like? You must answer each question with 4 separate statements. (for example, maybe your positive self-talk dream is making sure to tell yourself that you love yourself every morning as you rise and every morning before you go to bed......and it sounds like you reminding yourself that what happened to you when you were a child was outside your control and that you're not going to let your past dictate your future; maybe it tastes like a brand new dish you cooked at home because you tell yourself that it's time to try new things; maybe it feels like a massage at the elite country spa because you told yourself that you're going to start living your life now and that you've always deserved a life balanced between work and play.) Sounds, taste and feel and look...all need answers.

On a scale of 1-10 maybe rank health, wealth, relationships, and positive inner self talk. 10 means "excellent accomplishments already in this area". 0 means "really should explore subconscious programming in this area because achievement in this area has always been inconsistent or lacking."

Find the area where you believe you need the most help in and write down the limiting beliefs you have in those areas. If you have more than 1 of the 4 major areas to explore, then just do all 4.

Write down some of your limiting beliefs about relationships. Some examples are as follows – no one wants someone who has kids and is divorced – all the good men are taken – all the good women are taken – the only people left out there are crazy – all women want is money – all men want are young barbies - what if they cheat on me – I can't trust ever again – it takes just too much effort – I'll never find the perfect partner or in regards to wealth - I'm too old - everyone in my family are divorced or alone - I'm too big - my sexuality is lacking - I don't think my sex parts even work anymore - I don't want to get married again - I have no time to date - what if my kids don't like the people I date - I don't know where to find men - I don't know where to find women - I don't want to look desperate - I'm too scared to start over - what if I never find anyone again -it's better the devil you know than the devil you don't know - what if my ex doesn't like my new partner

Write down some of your limiting beliefs with wealth. Some examples are as follows - money is the root of all evil – I don't know how to make money – people with money aren't good people – it takes money to make money and I have no money - what if I lose what I have trying to make more money – what if I fail – I don't have anything people want to buy – what if I get rejected at the bank or I can't find any customers - what if someone tries to steal my money – I don't have the right degree – I didn't go the proper school – I don't have the right connections – I don't have anyone to help me - everyone in my family works a job - I don't know where to start - struggling is more noble - being rich means you're not as well liked as people who work hard - it's lonely to be wealthy - it's lonely at the top - if you work hard to be rich, you never see your family - you can't have your cake and eat it too - if it's too good to be true, it most likely is - you can't have it all - I don't have what it takes to be wealthy - I'm not good with people.

Write down some of your limiting beliefs with health. Some examples are as follows. - I don't like water - my diseases hold me back - no one has ever reversed the disease I have - my disease is genetic - they said my disease was rare - they don't even know what it is or what causes my disease - the exercise and healthy food will interfere with my medication - I have too many social obligations - how do I not drink - I'm exhausted after work and can't exercise - my body hurts too much - I'll just never be fit - it's just not me - what's the sense, I just gain it back anyway - I've tried and failed more times than I can count - isn't wine healthy -I don't have the time to exercise – I don't even know what to do – I can't control my diet – I am big boned – everyone in my family is overweight and has diseases - I can't fix two types of meals, one for me and one for my kids and partner - it's too expensive to eat well - how do you know it's really organic - what if I lose friends - my genetics are to blame - I never learned how to cook - I don't like vegetables.

Write down some of your limiting beliefs with respect to positive self-talk. What are the most common examples of the inner dialogue you say daily to yourself, which doesn't serve to program your subconscious for success? Some examples are as follows.... – I can't think positive thoughts with no money – my kids drive me crazy – the people I work with are idiots – I can't even think at all I'm so busy – if I had something to be positive about, I would be - easy for you to say - I don't even know how to do that - that positive new age stuff is all bologna - I don't believe in that stuff - I'm a born loser - I constantly fail and don't know why - my friends don't talk like that at all - it's hard to be positive all day when you're surrounded by negative people - I can't get what I want - I always have bad luck - I take one step forward and two steps back all the time - I always seem to look at the negative side of things.

After you write down your personal limiting beliefs in each category...... try to identify where those beliefs came from a) mother b) father c) family member d) greater culture tribe or media influence. Do they sound like something your mother or father said, sometimes in those exact words or something you had you had to believe, so you fit into the family better? Go back up and write down mother, father, or media.... where those limiting beliefs came from.

Elanvital Coaching