Name
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First Name
Last Name
Birthday
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MM
DD
YYYY
Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Primary Phone
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Email
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Social Media (if relevant to our work together)
Name
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First Name
Last Name
Relationship to You
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Primary Phone
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(###)
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Please list any family members (spouse, children, parents, etc.) whose names may come up in our sessions (name, gender, age, relationship to you). This saves you the trouble of having to explain during the session.
Do you have an intimate relationship (husband, wife, life partner, boyfriend, or girlfriend)?
If yes, what is the quality of that relationship? What is great about it? What needs work?
If you are a parent, how do you feel about this role? What is working? What needs to change?
Do you have close friendships, confidants, or people you can rely on?
If yes, please describe these relationships, paying particular attention to the value they bring to your life.
If no one readily comes to mind, how do you feel about the relationships in your life? Are you happy with your level of connection and support? Or are you looking for something different?
Are there any relationships in your life that are particularly challenging? Please explain.
What is your occupation?
Do you enjoy your work? Why or why not?
Is there anything you would like to shift or change in your work?
Please list any co-workers whose names may come up in our sessions (name, working relationship to you). You do not need to list every employee, just those whose names are very likely to come up. This saves you the trouble of having to explain during the session.
Are you currently under treatment for any psychiatric or mental health conditions, or are you working with a therapist or other mental health professional?
If yes, please describe where you are with that at this point in time, any treatment you are currently undergoing, medications you are currently taking that are related to anxiety/depression/mood, and the last therapist/psychologist or other qualified medical professional from which you received treatment.
Have you ever, at any time in your life, undergone therapeutic treatment for any of the following: bi-polar/manic depression, post-traumatic stress, clinical depression, eating disorders, suicide attempts?
If yes, please give me a bit of context. What was happening? How recently was it an issue? How severe did you feel it was (most people have experienced some level of depression in their lifetime, but did the depression ever get to a point where you were not eating, sleeping, holding down a job, etc.)? Did you receive treatment? To what degree is this still a challenge?
Do you have any medical conditions that may be impacting your overall wellbeing or life satisfaction?
Do you have any concerns about your physical health or how you care for your body?
What is the current state of organization in your home/personal space? How often do you pick up the house? How cluttered is it? How often do you deep clean?
On a scale of 1-10, with 1 being “not at all satisfied with my home” and 10 being “wouldn't change a thing about my home,” how satisfied are you with your home environment? Why?
Do you have a happy place, some physical place you can go to and feel completely at peace and fully yourself? If yes, please describe. If no, describe what that place might look like.
What is the current state of your financial affairs? (For example, are things in order, with a regular process for checking in on your money, solid plans that are followed for paying down any debt, consciousness around not getting into debt that is backed by accountability?)
On a scale of 1-10, with 1 being “not organized around money” and 10 being “hyper-organized and possibly over-organized around money,” how accountable are you with your finances?
Do you have a reference point that you use to connect with something larger than the human experience (e.g., God, higher power, the Universe, Mother Earth, universal connection)? (No is okay!) If yes, please describe.
What brings you to life coaching? Describe what you hope to get out of a coaching relationship.
Tell me your three biggest strengths.
Tell me your three worst fears.
Have there been any significant events in your life that you would describe as pivotal or life changing? If yes, please describe.
Are there things you feel you must accomplish during your lifetime so that you will consider your life to have been satisfying and well-lived, with few regrets?
Maybe you've accomplished one or more of these goals already. If so, please describe.
If you had to narrow your coaching goals down to three things, what would they be? When you write your goal, make it both specific and measurable. (For example, “find a new job” is vague, whereas “determine the industry I’d like to work in and then create three action steps to get a job in that industry” is specific and measurable.) Don’t worry! These goals may shift as you move forward, and that’s okay—in fact, it’s part of the process.
Which of these goals is most important to you?
If you trusted your coach enough to give her tips on how to support you most effectively, what tips would you give?
What insights would you share about how to help you when you are particularly resistant, stuck, or frustrated?
What’s the best thing to say to you if you are feeling particularly triggered and in a mood to blame someone else for your stuff?
If you had a three-year goal and the continuing services of a coach to make it happen, what would that goal be? What difference would working with a coach make?
