Name
*
First Name
Last Name
Address
Phone (Mobile)
*
Phone (Home)
Email
*
Birthday
MM
DD
YYYY
Occupation
Employer
Are you currently married or dating anyone?
If yes, what's their name?
Do you have any children?
If yes, what's their names and how old are they?
How satisfied are you with your life?
Please answer the following according to how much you agree or disagree with each statement:
I am satisfied with my physical health.
I am satisfied with my emotional and mental health.
I am satisfied with my career.
I am satisfied with my finances.
I am satisfied with my marriage/romantic relationship.
I am satisfied with my home life.
I am satisfied with my extended family.
I am satisfied with my friends/social life.
I am satisfied with my recreational and leisure time.
I am satisfied with my lifestyle (degree of business and life balance).
I am satisfied with my personal life fulfillment.
I am satisfied with my spiritual health/life.
I am satisfied with my church/religious life.
I am satisfied with my physical comfort (housing, neighborhood, possessions, car, etc.).
Why do you want coaching? Be as specific as possible.
Example: “I want to start an exercise program to gain more energy and to lose 30 pounds.”
Are you or have you ever been in counseling or therapy?
If yes, explain.
Describe your spirituality. What is your relationship with God? In what ways do you sense God might be challenging you, nudging you in a different direction, or trying to get your attention.
What are the most important things (good and bad) happening in your life right now?
In what ways would you like your life to be different one year from now? Be specific.
What is getting in the way of these goals?
List at least three things you procrastinate at -- the things that you’ve been putting off.
What, if any, are your concerns about coaching?
What are your primary stressors?
Why did you select me as your coach?
What would you like me to do if you get behind in progress toward your goals?
How do you like to be supported or held accountable?
What else would you like me to know about you?
Thank you!
This information will be used in our upcoming session to help evaluate your needs and how best we can begin working together.
I’m looking forward to our first session!
