New Client Focus Form

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Your Name* (required)

Nickname

Home number* (required)

Business number

Fax number

Mobile number

Office address

Home address

Your Email* (required)

Where did you hear about me?* (required)

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Web page

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Date of Birth*

Occupation*

Significant other's name

Significant other's date of birth

Children names and ages

Identify three main areas that you want held as your main focus during the coaching relationship. For each focus area, provide a simple heading and a description of a measurable result. This will be over the next 3 months time. For example: Be more productive: I have a system to follow up on calls and letters, I’m on time, I get all tasks accomplished, and I have realistic goals for new projects.*

What are the 3 biggest changes you want to make in your life in the next 3 years so that you will be on a path to living a life with no regrets?*

If there were a secret passion in your life, what would that be?*

What would you say have been your 3 greatest accomplishments to date?*

What is the hardest thing in life that you have had to overcome?*

What major transitions have you had in the past two years? (New decade of life, new relationship, new job, new role, new residence, etc.)*

Have you worked with a coach or been in therapy before?*

If so, what worked well for you and what did not?*

Who are the key people in your life and what do they provide you?*

What’s missing in your life? What would make it more fulfilling?*

What are you learning/accepting about yourself at present?*

Rate the amount of stress in your life right now (1=low, 10=high)*

What are your primary stressors?*

List 5 things that you are tolerating in your life right now.*

List 5 adjectives that describe you at your best*:

List 5 adjectives that describe you at your worst*:

What motivates you?*

What are your 3 major concerns/fears about yourself?*

What are your 3 major concerns fears about life?*

What would you like me to do when you get behind in your goals? How do you like to be held accountable?*

Do you have a personal or professional Vision? If so, what is it?*

What would you like to contribute to the world?*

What is a dream or goal you have given up on?*

What part of yourself have you given up on?*

If you continue to live as you do, what regrets will you have?*

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After submission you will be redirected to schedule your appointment.

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