Questionnaire

First name

Last name

Email

Phone

What inspired you to apply to the Connected Within Program?

How would you describe your current relationship with yourself in a few sentences?

What are your main challenges right now (emotionally, mentally, or spiritually)?

How connected do you currently feel to yourself on a scale of 1–10? (1 = disconnected, 10 = deeply connected)

What does self-connection mean to you personally?

What practices, if any, do you currently engage in for personal growth or mindfulness? (e.g., journaling, meditation, therapy, coaching, breathwork, yoga, etc.)

What patterns or limiting beliefs do you notice repeating in your life that you’d like to transform?

The Connected Within Program involves inner work, holistic and neuroplasticity practices, and emotional reflection. Are you ready to dedicate time each week (approximately 80 minutes for live sessions plus 20–30 minutes for personal practices)?

Yes, absolutely

I’m willing to commit

Not sure yet

Other

Which of the following outcomes resonate most with what you hope to gain? (Select up to three)

Healing past emotional wounds

Gaining clarity about my next chapter

Building self-trust and confidence

A deeper connection with myself

Creating healthier boundaries and relationships

Continue my personal growth

What is your biggest intention for joining the Connected Within

How would your life change if you felt more self-connected, grounded, and at peace within yourself?

Is there anything else you’d like Paola to know about you or your journey before starting?

Connected Within

16-Week Group Program

Questionnaire

© 2025 Paola Baharav Transformational Coaching, LLC