Please fill out this form. Once completed a copy will be sent to me and to you.
Thank you!
| Your Full Name |
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| Full Mailing Address |
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| Phone # |
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| Email |
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| Birthday |
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| Referred By |
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| Relationship Status |
| YesNo |
| Spouse/Partner Name |
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| What are the three biggest changes you want to make in the next 3 months? |
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| What are the 3 biggest changes you want to make over the next 3 years? |
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| What are you most wanting to achieve? And are you ready for it? |
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| What would you say have been your 3 greatest accomplishments to date? |
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| What is the hardest thing in your life that you have ahd to overcome? |
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| Who are or have been your major role models and why? |
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| Have you ever worked with a coach before or a similar one-to-one adult relationship? If yes, what worked well for you and what did not work in the relationship(s)? |
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| What major transitions have you had in the past two years? Entering or approaching a new decade, a new relationship, a new career, a new role, a new residence, chang in children's ages/stages, etc? |
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| What improvements would you like to make in your family /home life? |
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| What improvements would you like to make in your financial situation |
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| What improvements would you like to make in your practice and professional life? |
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| What improvements would you like to make in your personal character? |
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| What improvements would you like to make in your relationships |
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| What improvements would you like to make in your leisure time? |
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| What improvements would you like to make in your self-care? |
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| What improvements would you like to make in your learning? |
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| Who are the key people in your life and what do they provide for you? Do you have a mentor? |
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| Is you life one of your choosing? If not, which parts are being chosen for you? |
| YesNo |
| What is your favorite part of your typical day? |
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| What is your least favorite part of your typical day? |
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| Looking at the past six months of your life, do you like the direction your life is moving in? |
| YesNo |
| On a scale of 1 to 5, 5 high, rate the amount of stress in your life right now |
| Less True - 1 2 3 4 5 - More True |
| What are your primary stressors? |
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| List five things that you are tolerating or putting up with in your life at present. (examples: staff who don’t take initiative, non-cooperative peers, poor management, information you can’t find, corporate politics, job dissatisfaction, career plateau, etc.) |
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| List five adjectives that describe you at your best. |
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| List five adjectives that describe you at your worst. |
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| What are your 3 major concerns/fears about yourself? |
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| What are your 3 major concerns/fears about life? |
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| What motivates you? |
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| What are you learning/accepting about yourself at present? |
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| What would you like me to do if you get behind on your goals? |
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| Do you understand that you are 100% responsible for your own results? |
| YesNo |
| Are you committed to taking new actions to improve yourself, your life and your practice? |
| YesNo |
| Do you understand that you are free to use what works for you and leave the rest? |
| YesNo |
| How will you know when you are receiving value (i.e your money's worth?) |
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| What types of approaches discourage you or take away your motivation? |
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| In what way might your internal saboteur show up in our work together that i should be aware of ? |
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| Do you enjoy self-assessments and improvement programs? |
| YesNo |
| Do you like brainstorming strategies? |
| YesNo |
| Do you like support, encouragement and validation? |
| YesNo |
| Do you like insight into who you are and your potential? |
| YesNo |
| Do you like painting a vision of what you can become or accomplish? |
| YesNo |
| Do you like exploring and removing blocks and obstacles to your success? |
| YesNo |
| Does accountability; checking up on goals work for you? |
| YesNo |
| Do you like working through self improvement programs together? |
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| Do you want to design action steps? |
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| Do you have a personal or professional vision? if so what is it? |
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| What would you like to contribute to the world? |
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| What do you think is NOT possible to achieve in your lifetime that you wish you could? |
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| What is a dream or goal you have given up on? |
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| What part of yourself, if any, have you given up on? |
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| On a scale of 1-5 with 5 high, rate the quality of your life today. |
| Less True - 1 2 3 4 5 - More True |
| If you reach the age of 95 and continue to live you life and order your time the way you are right now, what regrets do you think you will have? (tip: complete the statement 'I wish i had...' Do not include things from the past-only thing you will regret if you continue your exact present path. |
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| This application does not imply in any way that we will be working together. It only means that when there is an opening we will begin a dialog about potentially working together. |
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Your Name:
Your Email: |