Today's Date
Name
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First Name
Last Name
Gender Pronoun
Date of Birth
Phone
Email Address
*
Address
Occupation/Career
Hours of Work/Week
Relationship Status (Optional)
Children and Ages
2-3 Specific intentions/aspirations/goals I want to achieve in the next 3-12 months in my life are...
Biggest block or obstacles to accomplishing my goals are...
What I risk if I do not pursue the above named intentions/aspirations/goals are...
Major role models in my life so far are.... (Name 1 to 3 people and your relationship to them)
Major transitions I have had in the past two years are... (for example - new job, new relationship, new decade in life, new life role, new residence, changes in children's ages/stages of life, separation, divorce, death of a loved one, birth of a child)
Key people in my life and what do they provide for me currently are...
Is your life one of your choosing? If not, which parts are being chosen for you?
On a scale of 1-10, 10 being HIGHEST, provide a number that represents your current level/degree of stress:
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10
My primary stressors are... (List all that apply)
5 things that I am tolerating or putting up with in my life at present which I am dissatisfied with are... (for example -job dissatisfaction, negative relationships, sense of lack, loss of direction in life, chronic fear/anxiety, loneliness, lack of self-esteem)
A personal or spiritual vision for myself is...?
A dream or goal I (may) have given up on...
What I am ready to reclaim/implement/practice with the help of my coach is...
What types of approaches/styles/behaviors discourage you or take away your motivation?
Brainstorming strategies together
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Support, encouragement, validation
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Accountability: Checking up on goals
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Suggesting or designing action steps
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Strategic planning
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Insight into who you are and your potential
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Exploring and removing blocks and obstacles to your success
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Working through self-improvement programs together
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Painting a vision of what you can become or accomplish
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Directness: Asking hard questions; challenging you to move forward
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10
