Name
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First Name
Last Name
Preferred Pronouns
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Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
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Phone
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(###)
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Occupation
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Date of Birth
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MM
DD
YYYY
Marital Status
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Spouse’s/Partner's Name
Names/ages of Children
Overall Health
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Previous/Current Psychological Treatment (why, when, how long)
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Previous/Current Coaching (why, when, how long)
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Medications currently taking
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Instructions: This tool is to support you to reflect on where you would like to be in specific areas and where you currently are. Please be honest with yourself, this isn’t an assessment. We will use the tool as a starting point for reflecting and creating the coaching outcome together. For each of the below areas, think about what an ideal life would look like for you. Then rate out of 10, how satisfied you currently feel in this area. 1 = very dissatisfied, whereas 10 = fully satisfied. Use the first number (score) that pops into your head, not what you think it should be. To support you to rate your satisfaction in each area, we have given you some examples of what a fulfilled life might look like in each area. However, please don’t limit yourself to these examples and instead focus on what is important to you in that area.
From the above areas, which area of your life represents the biggest gap between what you deeply desire and how you life is currently showing up?
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Which areas in your life and/or work do you most want to impact through this program?
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What is it you most want to create in your life right now? What would success look like?
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What have been the biggest challenges that have been affecting your life?
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List 5 qualities you appreciate most about yourself and 5 things about yourself that you struggle with
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Think about two people that you really admire. What inspires you about them?
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What activities do you most enjoy doing?
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What brought you to this very moment- to seek guidance?
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What would you most like to receive from me, as your guide? How can I best support you in this program?
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What kind of new dream are you looking to create? Tell me about where you want to be or how you want to feel.
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Is there any other background information that would be relevant for me to know? e.g. work, health or relationships, etc.
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Why do you want to work with me? Allow yourself to speak from your heart. There is no right or wrong answer!
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This program is designed for those who are committed to embarking on this transformative journey and ready to dive deep and do the work. Are you prepared to commit to this path and seek profound changes in both your inner and outer dream?
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