PLEASE TELL ME ABOUT
(In addition to this form, please feel free to send a picture or
yourself, resume, or any other pertinent information.)
Congratulations on enrolling into a Personal Life Coaching Program.
Please take a few minutes to complete this form. All information is confidential and will be used exclusively by
me to assist you in creating the results to which you are committed.
Name (Please Print):
City _________________________ State
________ Zip code: __________________
Phone ______________ FAX ______________ Email
Please answer the following questions to assist
in being the best coach I can be for
Describe three items you most want to achieve or accomplish as a result of your
do you want to achieve these things?
What has prevented you from achieving them in the past?
will you know when you have achieved your goals?
What is most important to you in life?
What are you most grateful for in life?
7. What would you say have been your
3 greatest accomplishments to date?
8. What is the hardest thing in life
that you have had to overcome?
9. Who have been your major role
10. What major transitions have you had in the past couple of years? Some
examples might be ... a change in relationship status, a move, a new job, a new role, entering a new decade,
11. On a
scale of one to ten, ten being the high, rate the amount of stress in your life right
12. What are your primary stressors?
List 5 things you are tolerating or putting up with in
your life at present. Some examples may be
clutter, rude friends, a poor environment, conversations that need closure, etc.
What are the top three major fears in your life?
What motivates you?
What would you like me to do if you get behind on your goals?
What would you like me to do if you miss a coaching session?
18. How will you know when you are
receiving value (i.e. your money’s worth) from the coaching process?
19. What do you think is NOT
possible to achieve in your lifetime that you wish you could?