Coaching Questionnaire

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Contact Info
Name*
First Last
Email*
Phone (Day/Evening)
Cell*
Your Goals
What 3 changes do you MOST want to make in your life?*
What 3 changes do you MOST want to make in your life?*
As an adult, have you worked in one-on-one relationship (e.g., tennis coach, piano teacher, and therapist)?*
If yes, what worked well for you? What did not work well?*
What major changes have you experienced in the past two years? (ie. change of job, a new role, change in residence etc.)*
Your Life
On a scale of 1 – 10 (10 high), how fulfilled are you with the choices you’ve made in the last 6 months?*
On a scale of 1-10 (10 high), how much stress is in your life right now?*
What causes you stress?*
What are you tolerating in your life at present? (Examples: clutter, poor lighting, dented car, job dissatisfaction, dead plants, broken equipment, etc.)*
What 5 adjectives would someone use to describe you at your best?*
Adjective 1 Adjecive 2 Adjective 3 Adjective 4 Adjective 5
How would they describe you at your worst?*
Adjective 1 Adjective 2 Adjective 3 Adjective 4 Adjective 5
Rate your CURRENT level of satisfaction on a scale of 1-10 on the following areas:
Self-esteem/Self-image:*
Please enter a number from 0 to 10.
Career/Profession:*
Please enter a number from 0 to 10.
Finances:*
Please enter a number from 0 to 10.
Romantic relationships:*
Please enter a number from 0 to 10.
Parenting:*
Please enter a number from 0 to 10.
Spiritual Awareness:*
Please enter a number from 0 to 10.
Fun & Enjoyment:*
Please enter a number from 0 to 10.
Social interactions:*
Please enter a number from 0 to 10.
Physical health/well-being:*
Please enter a number from 0 to 10.
What concerns do you have about life?*
What causes you to feel motivated?*
Potential & Possibility
Where would you like to see yourself in 2 years?*
What intentions do you have for your life presently?
On a scale of 1-10 (10 high), what is the quality of your life today.*
If you could choose one emotion/feeling to have following a coaching session, what emotion/feeling would that be?*

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Adjective 1	Adjecive 2	Adjective 3	Adjective 4	Adjective 5

Adjective 1	Adjective 2	Adjective 3	Adjective 4	Adjective 5

Contact Info

Your Goals

Your Life

Rate your CURRENT level of satisfaction on a scale of 1-10 on the following areas:

Potential & Possibility

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