Rocks and Roots Coaching

Delete the programs that hold you back and live life on your terms.

Please complete the application below to find out if you are a good fit for the 8 week program.

Full Name

Phone

Date of birth

What is the primary problem or challenge(s) you are wanting to resolve or change in your life?

How long has this been a problem or an issue for you?

What do you feel like is the big thing holding you back from achieving what you want?

How would resolving this problem benefit your life?

What are your short term goals for your life? Think 6-12 months.

On a scale of (1-10), how optimistic or hopeful do you feel in the morning? 1 - not at all 10- extremely optimistic or hopeful

On a scale of (1-10) rate the following categories in your life. 10 being - everything is awesome and exactly where you want it to be. 1- terrible

Marriage/ Romantic Relationship/ Partner Status

Family Life- Kids

Family Life - Extended Family

Work

Physical Health

Physical Fitness

Contentment/ Fulfillment

Financial

Are you under the care of a doctor for any diagnosed mental health conditions? If yes, do you take any medications for those conditions? If yes, how would you describe how that treatment is working for you in managing the condition?

Terms and Conditions

Privacy Policy

Rocks and Roots Coaching LLC, 2025