Client Intake Questionnaire - EMOTIONAL & ENERGETIC ALIGNMENT PROGRAM (Mental and Emotional Coach Eduardo Robles)

WELCOME TO YOUR INNER JOURNEY

Thank you for choosing to begin this beautiful process of emotional healing, energetic alignment, and personal transformation.
This questionnaire is not a medical diagnostic tool. This is a safe, loving, private space for deep self-reflection, so that I can understand you, your current emotional landscape, and the energy you are bringing into this season of your life.

Click the button below to start.

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🔹 SECTION - PERSONAL INFORMATION

CLIENT ESSENTIAL INFORMATION

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1. Full Name

Paragraph answer

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2. Email Address

Paragraph answer

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3. Mobile Phone Number

Paragraph answer

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4. Age Group

A

17 or younger

B

18–20

C

21–29

D

30–39

E

40–49

F

50–59

G

60 or older

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5. Current Marital Status

A

Married

B

Widowed

C

Divorced

D

Separated

E

Single

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6. If you have children, please write their names and ages

Paragraph answer

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7. Highest Level of Education Completed

A

Choice Elementary School

B

Middle School

C

High School

D

Technical / Vocational Training

E

College Degree

F

Postgraduate Degree (Master’s, Doctorate, etc.)

G

None

H

New Choice

Pregunta 9 de 65

8. What best describes your current occupation?

A

Homemaker / Domestic work

B

Administrative work

C

Accounting / Finance

D

Sales or related fields

E

Marketing / Design

F

Education / Training

G

IT / Computing / Programming

H

Communications / Arts

I

Health / Wellness

J

Food & Beverage industry

K

Cleaning / Maintenance

L

Other

🔹 SECTION 1

Your Why & Your Current Season of Life

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1. What inspired you to seek emotional and energetic coaching at this moment of your life?

Paragraph answer

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2. In your own words, what is the situation, experience, or emotional moment that led you to feel the way you feel today, and made you realize you may need professional support?

Paragraph answer

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3. What would you like to learn, transform, balance, or strengthen within yourself?

Paragraph answer

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4. What are your most important goals for the next 6–12 months?

Paragraph answer

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5. If you could receive one major breakthrough from this process, what would it be?

Paragraph answer

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6. How would you rate your current level of self-awareness from 1 - 10 (awareness of your emotions, thoughts, and behaviors)?

A

1

B

2

C

3

D

4

E

5

F

6

G

7

H

8

I

9

J

10

🔹 SECTION 2

Your Story & Pivotal Life Moments

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1. What have you dedicated most of your time, focus, and energy to in recent years?

Paragraph answer

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2. Please describe 3 - 4 defining moments in your life and what each taught you.

Defining Moment 1 - Description and what I learned:

Paragraph answer

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Defining Moment 2 - Description and what I learned:

Paragraph answer

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Defining Moment 3 - Description and what I learned:

Paragraph answer

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Defining Moment 4 - Description and what I learned:

Paragraph answer

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3. What emotional wounds, recurring patterns, or unresolved experiences still feel active in your life?

Paragraph answer

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4. What strengths, gifts, or qualities have these experiences awakened in you?

Paragraph answer

🔹 SECTION 3

Beliefs, Identity & Inner Narrative

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1. What past limiting beliefs continue to affect you today?

Paragraph answer

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2. Where do you feel those beliefs originally came from? (Examples: parents, school, trauma, past relationships, environment)

(Open answer)

Paragraph answer

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3. What empowering beliefs do you hold today about life, yourself, and your potential?

Paragraph answer

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4. What is within your control?

Paragraph answer

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5. What is outside your control?

Paragraph answer

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6. How would you describe who you are at your core (beyond your roles and achievements)?

Paragraph answer

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7. What does your Inner Critic usually say to you?

Paragraph answer

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8. What would your Inner Champion want you to hear instead?

Paragraph answer

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9. What insecurities or fears show up most frequently for you?

Paragraph answer

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10. What truths, values, or inner certainties give you strength?

Paragraph answer

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11. What do you feel is missing or in need of nurturing in your life right now?

Paragraph answer

🔹 SECTION 4

Emotional World & Energetic Patterns

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1. Which positive emotions do you experience most often?

Paragraph answer

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2. Which difficult emotions show up most frequently?

Paragraph answer

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3. Emotional Deep Dive - Choose Positive Emotion 1 and describe: • Situation • Trigger • How I amplify it.

Paragraph answer

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4. Emotional Deep Dive - Choose Positive Emotion 2 and describe: • Situation • Trigger • How I amplify it.

Paragraph answer

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5. Emotional Deep Dive - Choose Difficult Emotion 1 and describe: • Situation • Trigger • How I manage it.

Paragraph answer

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6. Emotional Deep Dive - Choose Difficult Emotion 1 and describe: • Situation • Trigger • How I manage it.

Paragraph answer

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7. When you experience emotional discomfort (fear, stress, frustration), how do you normally respond?

A

I freeze

B

I avoid

C

I react impulsively

D

I breathe and face it

E

Other

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8. What activities, environments, or practices help you feel calm, centered, or grounded? (Meditation, walking, sport, gym, music, journaling, breathing, etc.)

Paragraph answer

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9. How often do you feel mentally present in your daily life?

A

Almost never

B

Sometimes

C

Half of the time

D

Almost always

🔹 SECTION 5

Habits, Mindset & Daily Patterns

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1. What is one habit you want to break, and one habit you want to build during this process?

Paragraph answer

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2. Do you tend to focus more on the result or on the daily steps required to get there?

Paragraph answer

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3. When you face a problem, do you tend to focus on the problem, the emotion, or the solution?

Paragraph answer

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4. In which areas of your life would you like to develop a growth mindset?

Paragraph answer

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5. Where in your life do you stay in your comfort zone, and what would stepping into the growth zone look like?

Paragraph answer

🔹 SECTION 6

Stressors, Motivators & Energetic Vision

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1. What areas of your life currently generate the most stress or emotional tension?

Paragraph answer

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2. How do you usually decompress or regulate stress?

Paragraph answer

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3. Who are the engines (people who uplift and energize you) in your life?

Paragraph answer

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4. Who are the anchors (people who drain or discourage your energy)?

Paragraph answer

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5. Describe your ideal life. The life you would love to create from your most authentic energy.

Paragraph answer

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6. From 1-10, how would you rate your current energy level today?

A

1

B

2

C

3

D

4

E

5

F

6

G

7

H

8

I

9

J

10

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7. What do you believe is influencing that number?

Paragraph answer

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8. What are you most grateful for today?

Paragraph answer

🔹 SECTION 7

Support, Safety & Current Emotional Resources

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1. Are you currently receiving therapy, counseling, or any clinical emotional/mental support?

Paragraph answer

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2. Is there anything else you feel I should know about your emotional world, your story, or your current situation before we begin?

Paragraph answer

CONFIDENTIALITY & ETHICS DISCLAIMER

CONFIDENTIALITY & ETHICS DISCLAIMER

Your information, your story, and your emotional experiences are sacred.
Everything you share in this questionnaire will be treated as:

✔ Strictly confidential

✔ For internal coaching reference only

✔ Never shared with anyone without your explicit written consent

This coaching program is:
• Non-clinical

• Non-diagnostic

• Non-therapeutic
• Focused on emotional wellness, mental clarity, energetic alignment, and personal empowerment

• It is not a substitute for therapy or medical/psychological treatment.

My commitment is to offer you a space that is:
• Safe

Energized
Compassionate
Present
Creative
And aligned with your highest potential

CONGRATULATIONS

By completing this questionnaire, you have already taken a powerful first step toward:
• Healing

Clarity
Emotional freedom
And the activation of your best energy

I am honored to support you in this journey.

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Correo electrónico

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Client Intake Questionnaire - EMOTIONAL & ENERGETIC ALIGNMENT PROGRAM (Mental and Emotional Coach Eduardo Robles)

Click the button below to start.

🔹 SECTION - PERSONAL INFORMATION

1. Full Name

2. Email Address

3. Mobile Phone Number

4. Age Group

5. Current Marital Status

6. If you have children, please write their names and ages

7. Highest Level of Education Completed

8. What best describes your current occupation?

🔹 SECTION 1

1. What inspired you to seek emotional and energetic coaching at this moment of your life?

2. In your own words, what is the situation, experience, or emotional moment that led you to feel the way you feel today, and made you realize you may need professional support?

3. What would you like to learn, transform, balance, or strengthen within yourself?

4. What are your most important goals for the next 6–12 months?

5. If you could receive one major breakthrough from this process, what would it be?

6. How would you rate your current level of self-awareness from 1 - 10 (awareness of your emotions, thoughts, and behaviors)?

🔹 SECTION 2

1. What have you dedicated most of your time, focus, and energy to in recent years?

2. Please describe 3 - 4 defining moments in your life and what each taught you. Defining Moment 1 - Description and what I learned:

Defining Moment 2 - Description and what I learned:

Defining Moment 3 - Description and what I learned:

Defining Moment 4 - Description and what I learned:

3. What emotional wounds, recurring patterns, or unresolved experiences still feel active in your life?

4. What strengths, gifts, or qualities have these experiences awakened in you?

🔹 SECTION 3

1. What past limiting beliefs continue to affect you today?

2. Where do you feel those beliefs originally came from? (Examples: parents, school, trauma, past relationships, environment) (Open answer)

3. What empowering beliefs do you hold today about life, yourself, and your potential?

4. What is within your control?

5. What is outside your control?

6. How would you describe who you are at your core (beyond your roles and achievements)?

7. What does your Inner Critic usually say to you?

8. What would your Inner Champion want you to hear instead?

9. What insecurities or fears show up most frequently for you?

10. What truths, values, or inner certainties give you strength?

11. What do you feel is missing or in need of nurturing in your life right now?

🔹 SECTION 4

1. Which positive emotions do you experience most often?

2. Which difficult emotions show up most frequently?

3. Emotional Deep Dive - Choose Positive Emotion 1 and describe: • Situation • Trigger • How I amplify it.

4. Emotional Deep Dive - Choose Positive Emotion 2 and describe: • Situation • Trigger • How I amplify it.

5. Emotional Deep Dive - Choose Difficult Emotion 1 and describe: • Situation • Trigger • How I manage it.

6. Emotional Deep Dive - Choose Difficult Emotion 1 and describe: • Situation • Trigger • How I manage it.

7. When you experience emotional discomfort (fear, stress, frustration), how do you normally respond?

8. What activities, environments, or practices help you feel calm, centered, or grounded? (Meditation, walking, sport, gym, music, journaling, breathing, etc.)

9. How often do you feel mentally present in your daily life?

🔹 SECTION 5

1. What is one habit you want to break, and one habit you want to build during this process?

2. Do you tend to focus more on the result or on the daily steps required to get there?

3. When you face a problem, do you tend to focus on the problem, the emotion, or the solution?

4. In which areas of your life would you like to develop a growth mindset?

5. Where in your life do you stay in your comfort zone, and what would stepping into the growth zone look like?

🔹 SECTION 6

1. What areas of your life currently generate the most stress or emotional tension?

2. How do you usually decompress or regulate stress?

3. Who are the engines (people who uplift and energize you) in your life?

4. Who are the anchors (people who drain or discourage your energy)?

5. Describe your ideal life. The life you would love to create from your most authentic energy.

6. From 1-10, how would you rate your current energy level today?

7. What do you believe is influencing that number?

8. What are you most grateful for today?

🔹 SECTION 7

1. Are you currently receiving therapy, counseling, or any clinical emotional/mental support?

2. Is there anything else you feel I should know about your emotional world, your story, or your current situation before we begin?

CONFIDENTIALITY & ETHICS DISCLAIMER

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2. Please describe 3 - 4 defining moments in your life and what each taught you.

Defining Moment 1 - Description and what I learned:

2. Where do you feel those beliefs originally came from? (Examples: parents, school, trauma, past relationships, environment)

(Open answer)