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1) a) For each of the following life areas, how would you rate your life out of 10 (10 being you can't imagine it could possibly be any better)?

Health	Money	Career	Family
Relationship(s)	Peace/Stress & Confidence	Own Business	Learning & Growth

b) Given these scores, what two areas are you willing to improve over the next 6 months to make the biggest difference to your life? (Maximum Two)

Health	Money	Career	Family
Relationship(s)	Peace/Stress & Confidence	Own Business	Learning & Growth

2) What is one goal (target) you could achieve by 6 months from now that would make a BIG difference to your life?

3) If you could have more of ONE thing in your life right now, what would it be?

4) What three things are you most tolerating or putting up with in your life?

1)			2)		3)
Which of these are you ready to handle?

5) Please write down one thing you would like to have or achieve, but are not sure if or how you can have it?

6) Assuming all human beings have some way of holding back or sabotaging their life, which would be your favourite method?

Procrastination	Indecisive	Arrogant/ being right
Acting as 'Lone Range'	Tolerating	Not saying "No"
Controlling life /people	Not saying "Yes"	Following secondary goals (i.e. goals that won't ultimately make me happy)
Not always telling absolute truth		Other:

7) If you had a coach, what would you probably get from the coaching that would be most valuable to you? (3 maximum)

Challenge	Accountability	Focus	Support
Inspiration	Direction	Sounding Board	Ideas/ Strategies
Validation

8) How coachable do you suspect you are? (open to input and feedback; comfortable in partnership; ready to make changes)

Highly

Reasonably

I'm trouble

Required Fields Marked with *

10) Should we decide to work together, how affordable do you feel the coaching investment is for you?* (Coaching Fees)


Comfortable	Reasonably, assuming consistent results	A stretch, but OK if consistent results	I don't see how it could be worthwhile

11) If we both agreed coaching is a good move for you right now, what's your best guess at how long it might make sense for us to work together on these goals to really make a good impact? (more) *


1 month	3 months	6 months	12 months or more

I have read the section how you work with people :*

I understand that while I may choose to commit to a 3, 6 or 12 month coaching structure, I may still withdraw at the end of the first month if it is not what I expected:*

Primary Interest:*

Considering hiring a coach

Become a coach

Be coached for three months and THEN become a coach

One-off session simply to see what coaching is about
(I'm not looking for a coach right now)

If after this complimentary session we decided to work together, enter preferred start date* (More)

	Within the next 10 days
	Within the next 30 days
	Within the next 3 months

Do you require anyone else's agreement before setting up a 3-6 month coaching structure for yourself?*

No, I can make that decision alone (or I have my partner's and/or company's full support)

Yes, I would want to get the agreement of my partner or company first

Full Name : *
Company :
Email : * (Please check spelling)
Home Phone : *
Work Phone : *
Cell Phone :
State/Province :
Country : *
Human Check*: What is "pot" spelled backwards?
Comments :

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