Coaching Agreement & Intake Form

Please confirm you have read the Coach Service Agreement .

I have read the Coach Services Agreement and agree to the Policies and Disclaimer of Liability

What are the three biggest changes you want to make in your life in the next 3 months?

What are the three biggest changes you want to make in your life over the next 3 years?

What are you most wanting to achieve? And, do you feel ready for it?

What would you say have been your 3 greatest accomplishments to date?

What is the hardest thing in your life that you have had to overcome?

Who are or have been your major role models?

Have you worked with a coach before or a similar one-on-one adult relationship (e.g. tennis coach, piano teacher, therapist)?

Yes No

If yes, what worked well for you and what did not work in the relationship(s)?

What major transitions have you had in the past two years? Entering or approaching a new decade, a new relationship, a new job, a new role, a new residence, change in children’s ages/stages, etc.

Please list any improvements you would like to make in the following areas of your life.

Family/home life:

Financial situation:

Career or Business life:

Who are the key people in your life and what do they provide for you?

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

What's the favorite part of your typical day?

What's your least favorite part of your typical day?

Looking at the past six months of your life, do you like the direction your life is moving in?

On a scale of 1 to 10, 10 high, rate the amount of stress in your life right now.

What are your primary stressors?

List five things that you are tolerating or putting up with in your life at present. (examples: info you can’t find, clutter, rude friends, poor lighting, tight shoes, dented car, job dissatisfaction, dead plants, broken equipment, old appliances, etc.)

List five adjectives that describe you at your best.

List five adjectives that describe you at your worst.

What are your 3 major concerns/fears about yourself?

What are your 3 major concerns/fears about life?

What are you learning/accepting about yourself at present?

What would you like me to do if you get behind in your goals?

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

Are you able and willing to pay the monthly coaching fee?

Yes No

What types of approaches discourage you or take away motivation?

Do you enjoy self-assessments and improvement programs?

Yes No Maybe

Here are ways coaching clients work with me. Please check the ones that interest you.

Potential & Possiblity

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

What would you like to contribute to the world?

What do you think is NOT possible to achieve in your lifetime that you wish you could?

What is a dream or goal you have given up on?

On a scale of 1 to 10 with 10 being the highest, rate the quality of your life today.

If you reach the age of 100 and continue to live your 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 things you will regret if you continue on your exact present path.

Your Information

Your Goals

Your History

Your History

Improvements

Yourself

Coaching You

Potential & Possiblity