Long Form Questionnaire - Career & Life Coaching

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- Step 1 of 13

Today's Date *

Name *

First

Last

Phone Number *

Best Time to Call? *

Is it okay to leave messages at this number? *

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

How long have you been living at this address? *

Occupation *

Age *

For appointment scheduling, what are the best:

Times of Day: *

Days of the week: *

Marital Status *

Never Married
Married
Domestic Partnership
Divorced
Widowed

Please list the names and replationships of the five most important people in your life:

1. *

2. *

3. *

4. *

5. *

Do you have pets? *

If yes, please list:

Education: *

How would you rate your overall physical health? *

Excellent
Great
Good
Fair
Poor

Do you have any sleep problems? *

If yes, please describe:

Are you dealing with any past or current addictions? *

If yes, please describe:

Are you currently seeing a therapist? *

If yes, please describe what issues you are addressing in therapy:

Are you currently taking any medications? *

If yes, please list:

Are you usually: *

Early
On Time
Running Late

Do you exercise regularly? *

If yes, please describe what you do and how often:

How often do you watch television? *

What are your favorite hobbies and sports? *

What do you do for fun? *

What is your spirtual orientation? *

When you treat yourself, what are things you like to do? *

What's your idea of a perfect vacation? *

How did you hear about me? *

Goal Setting Worksheet

Please provide the following information and answer the questions below:

Please list your top three goals:

Goal #1 *

This goal is important to me because: *

Some barriers in my life that might get in my way of achieving this goal are: *

Goal #2 *

This goal is important to me because: *

Some barriers in my life that might get in my way of achieving this goal are: *

Goal #3 *

This goal is important to me because: *

Some barriers in my life that might get in my way of achieving this goal are: *

New Client Questionnaire

Provide respones to each statement: *

	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
I feel that I am capable of having the life I really want.	Strongly DisagreeI feel that I am capable of having the life I really want. Strongly Disagree	DisagreeI feel that I am capable of having the life I really want. Disagree	NeutralI feel that I am capable of having the life I really want. Neutral	AgreeI feel that I am capable of having the life I really want. Agree	Strongly AgreeI feel that I am capable of having the life I really want. Strongly Agree
I am open to experimenting with new ways of doing things in my life.	Strongly DisagreeI am open to experimenting with new ways of doing things in my life. Strongly Disagree	DisagreeI am open to experimenting with new ways of doing things in my life. Disagree	NeutralI am open to experimenting with new ways of doing things in my life. Neutral	AgreeI am open to experimenting with new ways of doing things in my life. Agree	Strongly AgreeI am open to experimenting with new ways of doing things in my life. Strongly Agree
I am willing to be disciplined and follow through with my commitments.	Strongly DisagreeI am willing to be disciplined and follow through with my commitments. Strongly Disagree	DisagreeI am willing to be disciplined and follow through with my commitments. Disagree	NeutralI am willing to be disciplined and follow through with my commitments. Neutral	AgreeI am willing to be disciplined and follow through with my commitments. Agree	Strongly AgreeI am willing to be disciplined and follow through with my commitments. Strongly Agree
I am a positive person.	Strongly DisagreeI am a positive person. Strongly Disagree	DisagreeI am a positive person. Disagree	NeutralI am a positive person. Neutral	AgreeI am a positive person. Agree	Strongly AgreeI am a positive person. Strongly Agree
I hold myself fully accountable for the results I create in my life.	Strongly DisagreeI hold myself fully accountable for the results I create in my life. Strongly Disagree	DisagreeI hold myself fully accountable for the results I create in my life. Disagree	NeutralI hold myself fully accountable for the results I create in my life. Neutral	AgreeI hold myself fully accountable for the results I create in my life. Agree	Strongly AgreeI hold myself fully accountable for the results I create in my life. Strongly Agree
I have a clear vision for my life and what I am committed to accomplishing.	Strongly DisagreeI have a clear vision for my life and what I am committed to accomplishing. Strongly Disagree	DisagreeI have a clear vision for my life and what I am committed to accomplishing. Disagree	NeutralI have a clear vision for my life and what I am committed to accomplishing. Neutral	AgreeI have a clear vision for my life and what I am committed to accomplishing. Agree	Strongly AgreeI have a clear vision for my life and what I am committed to accomplishing. Strongly Agree
I do well when working with others.	Strongly DisagreeI do well when working with others. Strongly Disagree	DisagreeI do well when working with others. Disagree	NeutralI do well when working with others. Neutral	AgreeI do well when working with others. Agree	Strongly AgreeI do well when working with others. Strongly Agree
I live with a high level of integrity.	Strongly DisagreeI live with a high level of integrity. Strongly Disagree	DisagreeI live with a high level of integrity. Disagree	NeutralI live with a high level of integrity. Neutral	AgreeI live with a high level of integrity. Agree	Strongly AgreeI live with a high level of integrity. Strongly Agree
I am supported by the people in my life and they are committed to my success.	Strongly DisagreeI am supported by the people in my life and they are committed to my success. Strongly Disagree	DisagreeI am supported by the people in my life and they are committed to my success. Disagree	NeutralI am supported by the people in my life and they are committed to my success. Neutral	AgreeI am supported by the people in my life and they are committed to my success. Agree	Strongly AgreeI am supported by the people in my life and they are committed to my success. Strongly Agree
I am committed to my own personal growth and am willing to invest the necessary time and energy.	Strongly DisagreeI am committed to my own personal growth and am willing to invest the necessary time and energy. Strongly Disagree	DisagreeI am committed to my own personal growth and am willing to invest the necessary time and energy. Disagree	NeutralI am committed to my own personal growth and am willing to invest the necessary time and energy. Neutral	AgreeI am committed to my own personal growth and am willing to invest the necessary time and energy. Agree	Strongly AgreeI am committed to my own personal growth and am willing to invest the necessary time and energy. Strongly Agree
I am able to receive support and contribution from others.	Strongly DisagreeI am able to receive support and contribution from others. Strongly Disagree	DisagreeI am able to receive support and contribution from others. Disagree	NeutralI am able to receive support and contribution from others. Neutral	AgreeI am able to receive support and contribution from others. Agree	Strongly AgreeI am able to receive support and contribution from others. Strongly Agree

What influenced your decision to start working with a life coach? *

Have you ever worked with a life coach before? If so, please describe your experience. *

What part of your life is working well? *

What part of your life could be working better? *

What do you want to focus on first in your work with me? *

What are some obstacles that keep you from achieving your goals? *

What are your life values? What is most important to you? *

What is success in your opinion? *

If you knew you wouldn't fail, what would you love to do? *

What is your biggest fear? *

What is your biggest reoccurring complaint about yourself? *

What are your biggest personal strengths? *

What are your biggest personal weaknesses? *

taking orientation? Are