DR. SCOTT MASSEY
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COACHING INTAKE FORM
Before your appointment with Dr. Scott Massey, please fill out the form below to provide some background info and insight into what you are looking for with one-on-one coaching.
I am interested in one-on-one coaching regarding (choose all that apply):
Personal growth
Professional growth
Achieving/maintaining sobriety
Dealing with chronic pain
I have specific goals I want to achieve:
Yes, and I am on track to accompish them
Yes, but I'm not sure how to accomplish them
No, but I would like to set a few goals
My current top goals are:
I practice daily affirmations
Yes, I practice them regularly
No, but I am interested in writing and reciting them
I am not sure what daily affirmations are
My current profession is:
I am satisfied with my current profession
Yes, I am fully satisfied with my profession
Yes, but I want to take the next step with my profession
No, I would like to change my profession
I would like to:
Achieve sobriety
Maintain sobriety
I have been drinking for:
Less than 1 year
1-5 years
6-10 years
10+ years
I have been sober for:
Less than 1 year
1-5 years
6-10 years
10+ years
My chronic pain is due to:
I have had chronic pain for:
Less than 1 year
1-5 years
6-10 years
10+ years
Submit
Thank you!