Intake Form

“If it doesn’t challenge you, it doesn’t change you.”

- Fred DeVito

As a coach, it's important for me to understand how you view the world in general and yourself in particular. Each person has a unique way of thinking and a unique way of interacting with those around them.

Answer each of these questions as clearly and thoughtfully as possible, expressing the best of who you are. These are "pondering" questions designed to stimulate your thinking in a particular way that will make our work together even more productive. It may take you several days to compose your responses to these questions. Thank you.

Name

First Name

Last Name

Birthday

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

What is your current occupation?

What are the 3 biggest changes you want to make in your life over the next 5 years?

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

What 3 goals do you want to achieve within the next 3 months? [must be specific, measurable, attainable, and relevant]

What are the biggest challenges you have in your life right now?

What's the most urgent challenge to prioritize that you want to work on in coaching?

How will you know you no longer need a coach?

On a scale of 1-10 how motivated are you in your work/personal life?

What two steps could you take immediately that would make the greatest difference in your current situation(s)?

What can your coach say to you when you are most "stuck" that will return you to action?

What would you like your coach to do if you struggle with your goals?

How will you know when you are receiving value from the coaching process and how effective it's been?

What approaches motivate/demotivate you?

How might you get in your own way or sabotage your coaching progress?

What do you find works for you to release stress?

How do you like to enjoy yourself?

What skills or knowledge are you developing? [skill or knowledge must be measurable]

What accomplishments must, in your opinion, occur during your lifetime so that you will consider your life to have been satisfying and well lived - a life of few or no regrets?

What do you consider your role to be in your household? In your community? In your country? In the world?

What are 3-5 things that are really working well for you?

What would make your life more fulfilling?

Who are the significant people in your life?

Tell me about a time(s) when you were operating at "peak performance", when things were going well for you, you were "on top of your game", you were pleased with what you were doing or accomplishing. What was going on? Who else was involved? How did you feel? [This is no time for modesty - tell it like it was]

What would you like from your coach during your sessions in ALL the following categories below. Score on a scale of 1 -10 where 1 is not important and 10 is extremely important.

Gaining clarity of issues Gaining an insight into who I am, my strengths, capabilities, and potential Providing encouragement and support Help to define goals Help to identify action and next steps Challenging you with difficult questions Making you accountable for your goals

Have you ever been diagnosed with a mental health condition?

If yes, what is your diagnosis?

If yes, are you currently in therapy?