INTAKE FORM

What are the 3 goals you want to achieve over the next three months?

What are the three biggest changes you want to make in your life over the next three years?

What would you say have been your three greatest accomplishments in your life to date?

What is the hardest thing you have ever had to overcome?

What major transitions have you had in the past two years? (i.e. – entering or approaching a new decade of life, a new relationship, a new job, a new role, a new residence, changes in children’s ages/stages of life, separation, divorce, death of a loved one, birth of a child, marriage, etc.)

Is your life one of your choosing? If not, which parts are being chosen for you?

On a scale of 1 – 10, 10 = HIGH, provide a number that represents your current level/ degree of stress? What are your primary stressors?

List five (5) things that you are tolerating or putting up with in your life at present. (i.e. – information you cannot find, rude people, poor lighting, tight shoes, dented car, job dissatisfaction, dead plants, broken equipment, old appliances, etc.)

What would you expect or like your Coach to do if you get behind on your goals?

How will you know when you are receiving value (i.e. – your money’s worth) from the Coaching process?

What types of approaches discourage you or take away your motivation?

How can a Coach best support you in the Coaching relationship? Place the following in order of importance : -Brainstorming Strategies Together -Support, Encouragement -Accountability;checking up on goals -Suggesting or designing action steps - Strategic Planning -Insight into who you are and your potential -Exploring & removing blocks

Do you have a personal or professional vision? If so, what is it?

What would you like to contribute to the world?

What part of yourself, if any, have you given up on?

On a scale of 1 to 10 (10= HIGH), rate the quality of your life today:

Thanks for submitting!