Name
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First Name
Last Name
Phone
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Email Address
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Referred By
What 3 changes do you most want to make in your life?
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What do you most want to achieve?
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And are you ready to achieve?
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As an adult, have you ever worked in a one-on-one relationship (e.g., tennis coach, piano teacher, and therapist)?
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If yes, what worked well for you? What did not work well?
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What major changes have you experienced in the past two years? (ie.. change of job, a new role, change in residence, divorce, health changes etc.)
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On a scale of 1 – 10 (10 high), how fulfilled are you with the choices you’ve made in the last 6 months?
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On a scale of 1-10 (10 high), how much stress is in your life right now?
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What causes you stress?
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What are you tolerating in your life at present? (Examples: clutter, overdue bills, job dissatisfaction, dead plants, overeating, broken equipment, etc.)
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What 5 adjectives would someone use to describe you at your best? (in no particular order)
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How would they describe you at your worst?
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What five adjectives would you use to describe yourself at your best?
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What five adjectives would you use to describe yourself at your worst?
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What concerns do you have about life?
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What causes you to feel motivated?
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What is your personal and/or professional vision?
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What intentions do you have for your life presently?
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If you could achieve at least 1 goal from our coaching sessions, what would it be?
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On a scale of 1-10 (10 high), what is the quality of your life today.
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I am thrilled to have the opportunity to be a part of your journey to ultimately increase your overall happiness, challenge yourself in thought and action, increase your confidence and accomplish your goals! Congratulations on making a conscious based decision to invest in YOU! You are definitely worth it!
I guarantee that I will do everything possible to help you get where you want to go. I am here for you so please do not hesitate to ask me questions. We are in this together!
