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Coach Screening Intake Form
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Please enable JavaScript in your browser to complete this form.
Name
*
First
Last
Email
*
Please respond as honestly as you can.
What do you feel is missing in your life?
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Satisfying Career
Money
Confidence / Esteem / Self-Image
Social Connections
Other
What do you think is keeping you from fixing this problem?
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Lack of Skills
Lack of Information
Confidence / Esteem / Self-Image
Social Connections
Lack of Support
Procrastination
What steps have you tried for dealing with these challenges?
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Books
Courses
Videos
Therapy
Coaching
Other
How do you normally make decisions?
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Research and analyze
Ask other people
Go with my instincts
How do you end relationships ( work, friendships, romantic, etc)?
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Discuss my concerns and try to resolve issues
Leave after notifying the other party
Disappear without giving notice
I am disciplined in paying my routine household bills.
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Yes
No
Are you willing to try new responses or approaches in order to overcome your challenges?
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Yes
No
for Are
Are you willing to talk about your fears and insecurities?
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Yes
No
Are you willing to do assignments outside of our sessions, such as watching videos or doing written exercises?
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Yes
No
Are you comfortable listening to feedback that might help you to make the changes you want?
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Yes
No
Do you have issues with severe depression, suicide thoughts, or other mental health issues?
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Yes
No
The fee for each session is between $100 to $180, depending on which coaching package you choose. Are you able to invest this amount on coaching sessions?
*
Yes
No
What qualities are you looking for in a coach?
Remember: Coaching is not magic. It will not transform your personality or create new talents. Coaching is about using your existing talents, strengths, and experiences to make the changes you want in life.
We recommend doing at least three sessions in order to complete the entire process 1 understanding your problem, 2 changing old thoughts, feelings, and behaviors, and 3 planning how to reach your goal. You are free to do the number of sessions you desire, but the impact might not be the same.
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