Welcome to M Club Wellness
At M Club Wellness, we offer compassionate therapeutic coaching designed to help you create lasting change and achieve personal growth. This survey is the first step toward understanding your unique needs and crafting a wellness plan tailored just for you. We recognize that reaching out for support is a big step, and we are here to walk this journey with you.
If you’re ready to commit to meaningful change, please fill out this survey. All information shared will be kept completely confidential, and we will handle it with care and respect.
Upon completion, you will be invited to a 90-minute Wellness Intake Session (fee: $150 + taxes). If you qualify, the assessment fee will be deducted from the program cost, and we will move forward in creating your personalized plan.
Please note: Our services are intended to support your growth but are not a replacement for therapy or medical advice. If you have medical concerns, we encourage you to consult with a healthcare professional.
Personal Background & Current Situation
How did you find your way to us?
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What has brought you to seek support at this time?
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What challenges or opportunities are you currently facing that led you to reach out?
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What is a personal success that you are proud of?
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How did you achieve it, and what fuelled your motivation along the way?
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What has been the greatest obstacle in achieving your goals?
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Have you taken steps to overcome it? If so, what has worked or not worked?
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In the next 6 to 12 months, what do you hope to achieve with our support?
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What would success look like for you, and how would it change your life?
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Self-Reflection & Emotional Insights
How content do you feel with your life right now? (1 = Very Dissatisfied, 10 = Very Satisfied)
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What personal beliefs or emotions are driving you to make a change now?
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Why is this transformation important to you at this stage of your life?
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Do you feel there are any subconscious beliefs or habits that have been holding you back?
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How have they impacted your journey so far?
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How do you prefer to receive guidance?
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Would you appreciate direct and clear feedback, or do you thrive more with gentle, positive reinforcement?
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How often do you feel you need to reflect on your progress to stay on track?
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Sleep Patterns & Habits
How would you describe your sleep habits? (Check all that apply)
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On average, how many hours of sleep do you get per night?
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Are there any habits you think might be affecting your sleep quality?
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Are you currently taking any medications for sleep or mental health (e.g., sleeping aids, antidepressants, anti-anxiety medication)?
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If yes, please specify the medication(s):
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Are you currently seeing a therapist for sleep issues, anxiety, depression, or any other mental health concerns?
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If yes, how long have you been seeing the therapist? How much improvement has their been?
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Services of Interest
Which of the following areas would you like to focus on? (Check all that apply)
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Therapeutic Coaching & Commitment
How ready are you to make changes in your life?
(1 = Not Very Ready, 10 = Fully Committed)
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What resources (time, energy, finances) are you willing to invest in making these changes?
Select a range:
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Final Thoughts
Is there anything else you’d like to share with us about your motivation or aspirations?
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What days and times would be most convenient for you to schedule a pre-screening session? (We will confirm the best times with you.)
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Confidentiality & Next Steps
Thank you for taking the time to share your thoughts with us. We deeply value your openness and trust. Once we review your responses, we will contact you to schedule your 90-minute Wellness Intake Session to develop a personalized plan for your journey.
Please know that all the information you’ve shared is completely confidential. We are here to support you with compassion, and we look forward to walking alongside you on your path to success and well-being.
