Surveypoint

Q1

I can be relied upon to be on time for all calls and appointments.

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5

Q2

I am willing to be accountable to another person.

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5

Q3

I am fully willing to do the work and let the coach do the coaching.

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5

Q4

I am willing to eliminate or modify any self-defeating behaviors that may limit my success.

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5

Q5

I am a self-starter and am willing to take the action necessary to achieve my goals.

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5

Q6

I will speak truth to the coach.

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5

Q7

I am willing to work with my coach in a partnership.

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5

Q8

I understand boundaries and actively set them in various areas of my life.

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5

Q9

I understand that coaching is not counseling, consulting, or mentoring. Coaching is an ongoing partnership that will help me produce fulfilling results in my personal and professional lives.

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5

Q10

I have core values that guide my moral foundation.

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5

Q11

I am open to talking about my dreams, visions, and goals.

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5

Q12

I am not afraid to take risks.

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5

Q13

I have thought through my goals and I have an inner peace guiding me.

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5

Q14

I am willing to consider new ideas, behaviors, and values.

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5

Q15

I have goals I want to achieve that have not yet been reached.

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5

Q16

YOUR SCORE:

Q17

Names and Ages of Children

Q18

If yes, please explain.

Q19

In what ways would you like your life to be different one year from now? Be specific.

Q20

List at least three things you procrastinate at -- the things that you’ve been putting off.

Q21

First Name

Name

Q22

Last Name

Name

Q23

Date

Q24

Postal / Zip Code

Address

Q25

Phone Number

Q26

Email

Q27

Street Address

Address

Q28

Street Address Line 2

Address

Q29

City

Address

Q30

State / Province

Address

Q31

Occupation

Q32

Date of Birth

Q33

Are you or have you ever been in counseling or therapy?

Yes

No

Q34

Marital Status

Q35

Significant Other's Name

Q36

Why do you want coaching? Be as specific as possible. Example: “I want to start an exercise program to gain more energy and to lose 30 pounds.”

Q37

What are the most important things (good and bad) happening in your life right now?

Q38

What is getting in the way of these goals?

Q39

What, if any, are your concerns about coaching?

Q40

Rate the level of stress in your life on a scale of 1 to 10. (1=low and 10=high)

Q41

What are your primary stressors?

Q42

Why did you select me as your coach?

Q43

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

Q44

How do you like to be supported or held accountable?

Q45

Getting Started -Form Fill

I can be relied upon to be on time for all calls and appointments.

I am willing to be accountable to another person.

I am fully willing to do the work and let the coach do the coaching.

I am willing to eliminate or modify any self-defeating behaviors that may limit my success.

I am a self-starter and am willing to take the action necessary to achieve my goals.

I will speak truth to the coach.

I am willing to work with my coach in a partnership.

I understand boundaries and actively set them in various areas of my life.

I understand that coaching is not counseling, consulting, or mentoring. Coaching is an ongoing partnership that will help me produce fulfilling results in my personal and professional lives.

I have core values that guide my moral foundation.

I am open to talking about my dreams, visions, and goals.

I am not afraid to take risks.

I have thought through my goals and I have an inner peace guiding me.

I am willing to consider new ideas, behaviors, and values.

I have goals I want to achieve that have not yet been reached.

YOUR SCORE:

Names and Ages of Children

If yes, please explain.

In what ways would you like your life to be different one year from now? Be specific.

List at least three things you procrastinate at -- the things that you’ve been putting off.

First Name

Last Name

Date

Postal / Zip Code

Phone Number

Email

Street Address

Street Address Line 2

City

State / Province

Occupation

Date of Birth

Are you or have you ever been in counseling or therapy?

Marital Status

Significant Other's Name

Why do you want coaching? Be as specific as possible. Example: “I want to start an exercise program to gain more energy and to lose 30 pounds.”

What are the most important things (good and bad) happening in your life right now?

What is getting in the way of these goals?

What, if any, are your concerns about coaching?

Rate the level of stress in your life on a scale of 1 to 10. (1=low and 10=high)

What are your primary stressors?

Why did you select me as your coach?

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

How do you like to be supported or held accountable?

What else would you like me to know about you?