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Intake form

Please take a moment to fill out the Intake form in full detail. This will enable me to thoroughly understand and address the specific issues you are experiencing. Your comprehensive responses are essential for providing the best support possible.

Name

First Name

Last Name

What services are you interested in?

Mentorship

Life Coaching

Sobriety & Recovery

1. What do you want to make sure you get from the coaching relationship? (maybe write down 2 or 3 things that occur to you)

2. How do you want me to be your coach?

3. What do you want to work on in coaching?

4. What two steps could you take immediately that would make the greatest difference in your current situation(s)?

5. What can I say to you when you are most "stuck" that will return you to action?

6. What changes might you need to make to help your coaching be successful?

7. If you trusted your coach enough to tell him or her how to manage you most effectively, what tips would you give?

8. What accomplishments must, in your opinion, occur during your lifetime so that you will consider your life to have been satisfying and well lived– a life of few or no regrets?

9. If there were a secret passion in your life, what would it be?

10. What do you consider your role to be in your local community? In your country? In the world?

11. If you could devote your life to serving others – and still have the money and lifestyle you need– would you do it? How would it look?

12. Write down 2-3 things that are really working well for you.

13. What do you do when you're really up against it?

14. If you had a 5-year goal and you had the continuing services of a coach to help you make it happen (and money was not an issue), what would that goal be? What differences would working with a coach make?

15. What's missing in your life? What would make your life more fulfilling?

16. What activities have special meaning for you?

17. Who are the most significant people in your life?

18. What have been the significant events in your life?

19. Tell me about a time(s) when you were operating at "peak performance" when things were going well for you, you were "on top of your game", and you were pleased with what you were doing or accomplishing. What was going on? Who else was involved? How did you feel? (This is no time for modesty – tell it like it was.)

20. Do you believe in God or the concept of a higher power? If so, describe the most useful and empowering aspects of your relationship with God. If not, what reference point do you use?