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Please take a moment to complete this questionnaire prior to your session!

Note: You will also receive an email with a link to this questionnaire to complete later if desired.

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First Name

Last Name

Please specify your area of interest (Select One)

Life Coaching

Address *

State *

City *

Postal code *

Occupation *

Date of birth *

Marital Status *

Partner's Name *

Children's Names and Ages *

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? Do you feel ready for it? *

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. althletic coach, piano teacher, therapist)? If yes, what worked well for you and what did not work in the relationship(s)? *

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 is your favorite part of your typical day? *

What is 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 being high, rate the amount of stress in your life right now. *

On a scale of 1 to 10, 10 being high, rate the level of fulfillment 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. (e.g. info you can't find, clutter, rude friends, poor lighting, dented car, job dissatisfaction, dead plants, old appliances, etc.) *

What are your 3 major concerns/fears about yourself? *

What are your 3 major concerns/fears about your life? *

What motivates you? *

What are you learning/accepting about yourself at present? *

What are your current views of life coaching? *

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? *

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

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

If you reach the age of 95 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 your exact present path. *

Why is it a must for you to create the changes you desire now? *

What has and will it cost you by not creating these changes? *

What has been preventing you from achieving this so far? *

Please write down anything additional you feel is important that you would like to share with your coach. *

Life & Leadership Coaching Certification

What is your time frame for being certified as a Life & Leadership Coach? *

Are you looking for a certification that is 100% virtual or a hybrid (virtual and in-person) program? *

What do you plan to do with your certification? *

Wellness Coaching

What is your age? *

What are your wellness goals over the next year? *

Business Coaching