Neuro Code Personal Development

Personal Development Intake Form

For best results, be as honest as you can when filling out this form. Please submit within 48 hours of scheduling your appointment.

Agreements

I understand that the personal information I share in this form will be used solely to prepare for and conduct coaching sessions, and will be kept confidential.I agree to answer every question as honestly as I can. I understand that the accuracy of my answers directly affects the quality of the coaching I receive.I take full personal responsibility for my own thoughts, feelings, and actions. I understand that real change requires my own commitment and effort.I understand that Trevor Dimick is not a licensed medical or mental health professional. Coaching is not a substitute for medical, psychiatric, or psychological treatment.I agree not to record, reproduce, or share any part of my coaching sessions, materials, or proprietary methods without express written consent.

Contact Information

First Name *

Last Name *

Cell / Text Number *

Email *

Life Assessment

How would you rate your life overall? 0

0 — Complete Failure10 — Complete Success

What is the main challenge you are facing? *

How often does this challenge impact your life? 0

0 — Never10 — Daily

Belief Statements

For each statement below, select the option that most honestly reflects your current experience. There are no right or wrong answers.

I am accepted the way I am

I am good enough

I feel free to make choices

I feel important in life

I generally trust people around me

I trust myself

I trust other people to make correct choices

I trust myself to make correct choices

I trust other people to support me

I trust myself to know what is best for me

I feel accepted by other people

I feel safe in my life

I feel emotionally overwhelmed in life

I feel mentally overwhelmed in life

I avoid problems in my life

I avoid conflict in my life

I am often critical of other people

Other people are often critical of me

I feel like I am failing in life

I feel neglected in life

I am honest in my daily dealings

People are usually honest with me

I easily forgive others

I usually show compassion toward others

I am usually respectful to others

People usually respect me

I enjoy setting goals and working towards them

I easily identify my weaknesses and want to improve

I avoid doing hard things in life

I am effectively regulating my emotions

I feel competent in life

I accurately understand other people's point of view

Other people typically understand my point of view

I feel confident communicating my needs

I believe my life is just and fair for the most part

I feel authentic in my life

I see my needs as more important than others'

I enjoy trying new things

Signature

Date *

Signature (type your full name) *