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Coaching Intake
pojwellness
2025-06-23T06:58:30+00:00
The Altar Within: Coaching Intake Form
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✨ Welcome
This form is the first step toward working together in sacred space. The Altar Within is a coaching journey designed to help you navigate life with intuition, integrity, and grace. Please take your time and respond with honesty and care. All responses are confidential and treated with the utmost respect. Once completed, I’ll reach out to schedule a free 15-minute clarity call.
Contact Info
Name
First
Last
Email
Phone
Preferred Contact Method
Email
Text
Phone Call
Where are you located?
City
State / Province / Region
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Pronouns
Age
Coaching Readiness & Preferences
Have you worked with a therapist, coach, or healer before?
(Yes / No) If yes, briefly describe your experience
What motivates you to seek coaching at this time?
On a scale of 1–10, how committed are you to making changes in your life right now?
How do you prefer to receive support and feedback?
Structured and directive
Reflective and exploratory
A blend of both
What type of accountability works best for you?
What days and times are generally best for sessions?
Weekdays
Weekends
Mornings
Afternoons
Evenings
Coaching Path
Which coaching path are you most drawn to?
🌱 Path of Embodiment – A 3-session journey for clarity, intention-setting, and soul-deep alignment. Includes personalized rituals and journal prompts. 💸 $400 (Partial scholarship: $300–$350)
🪶 Integration Session – A 60-minute session for grounding insights from ceremony, retreat, or spiritual awakening. 💸 $144 (Sliding scale: $122–$133)
🔥 Path of the Guide – Ongoing mentorship for space-holders, creatives, and therapists. Includes monthly 1:1s, weekly check-ins, and unlimited text support. 💸 $333/month (Partial scholarship: $250–$300)
🌙 I’m not sure yet – I’d love support choosing the path that’s right for me.
Intentions & Soul Focus
What would you most like support with at this time?
What draws you to this work with Dr. Gemma Andaya?
What does success in this journey look like for you?
Are you currently navigating any major transitions, healing processes, or spiritual experiences?
Are you open to bringing a loved one into a session if it would serve your process?
Yes
No
Maybe
Personal Wellness
Do you currently have any regular physical health practices (e.g., movement, nutrition, sleep routines)?
Are there any physical conditions or limitations you’d like me to be aware of?
How would you describe your relationship with your body right now?
Spiritual Health Practices
Do you engage in any spiritual or contemplative practices?
Meditation
Prayer
Ritual
Nature
Creative Arts
Other
Are you connected to a particular spiritual path or tradition?
How would you describe your connection to your intuition or higher self?
Support & Environment
Who are the key people in your support system right now?
Are there any environmental factors affecting your well-being?
Accessibility & Equity
Partial scholarships are available for: BIPOC clients Emerging leaders and healers Those experiencing temporary financial hardship This offering is part of my commitment to sacred reciprocity and inclusive care.
Are you interested in a scholarship?
Yes – I’d like to be considered for a partial scholarship
No – I’m able to pay the full amount
Unsure – Let’s discuss during our clarity call
🔹 Final Reflection
Is there anything else you’d like me to know before we connect?
💫 Closing Message:
Thank you for your thoughtful responses. I look forward to connecting with you soon to schedule our clarity call. May your path be blessed with guidance, gentleness, and grace.
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