Name

Date & Time of Birth

City, State and Country of Birth

Address

Phone

Email

Current Family (select one) Current Family (select one) Married Single Partenered

List of family members and ages

Previous health challenges - check all that apply Previous health challenges - check all that apply I do a good job of taking care of myself physically and emotionally I struggle with guilt and shame I am confident I set and hold boundaries for myself I am able to say “no” to others It is easy for me to ask for what I want or need My life is stressful and chaotic I feel like I am on a hamster wheel I find myself often saying, “When I have some time, I’m going to… “ I handle conflict well I always feel rushed and that there is not enough time I feel stuck I feel clear on the next steps to achieve my goals I understand and live my purpose

What are you looking for from the coaching experience?

How can your coach best support you during the coaching relationship?

What would you like your coach to do if you struggle with your goals?

How will you know when you are receiving value from the coaching process?

Describe your current meditation practices (if any).

Describe your eating habits and nutritional satisfaction.

What forms of physical activity and movement do you practice? Do they bring you joy?

Please describe your emotional well-being.

What are your current self-care practices?

Describe your sleep quality and length.

What is most important to you in your life and why?

Who in your life do you consider a support system and why?

Describe a moment or experiences from your past that has defined you.

What are your current stressors and obstacles to moving forward?

How do you get in your own way?

What is the greatest challenge you’ve had to overcome?

Are you currently under the care of a mental health professional, phycologist, or psychiatrist? If yes, what are they treating you for? Are you on any medications?

If you previously worked with a coach or therapist, please share your experience here.

Please list your spiritual or religious preference here

Additional information your coach should know: