Instructions

1

Please circle the number next to each of the following statements on the 1-4 scale as follows: 1 = not at all true, 2 = somewhat true, 3 = true, 4 = very true. You will then review the results of this quiz with your coach so that you can, together, determine whether coaching is the right option for you at this time so that you can gain maximum benefit.

2

Coaching Track* This field is required.

3

Client Email:* This field is required.

example@example.com

4

Start Date* This field is required.

Date

5

Phone Number

Area Code

Phone Number

6

I am prepared to be on time for all coaching appointments as scheduled, and to give at least 24 hours’ notice if I cannot.* This field is required.1 = not at all true, 2 = somewhat true, 3 =true, 4 = very true.

NT - 1

ST - 2

T - 3

VT - 4

7

I am willing to take an active role in the coaching* This field is required.1 = not at all true, 2 = somewhat true, 3 =true, 4 = very true.

NT - 1

ST - 2

T - 3

VT - 4

8

I am at a point in my life when I will try out new ideas and ways of doing things, as agreed with my coach.* This field is required.1 = not at all true, 2 = somewhat true, 3 =true, 4 = very true.

NT - 1

ST - 2

T - 3

VT - 4

9

I am willing to allow my coach to facilitate my process of discovery, and to freely share the insights I experience.* This field is required.1 = not at all true, 2 = somewhat true, 3 =true, 4 = very true.

NT - 1

ST - 2

T - 3

VT - 4

10

I am ready to willingly enter into a partnership with my coach to create a life that is even better than I have imagined alone.* This field is required.1 = not at all true, 2 = somewhat true, 3 =true, 4 = very true.

NT - 1

ST - 2

T - 3

VT - 4

11

I am willing to be open, honest and authentic with my coach.* This field is required.1 = not at all true, 2 = somewhat true, 3 =true, 4 = very true.

NT - 1

ST - 2

T - 3

VT - 4

12

I am willing to recognize my own “stuff” (limiting issues and beliefs) and to take responsibility for changing them when it is in my best interest.* This field is required.1 = not at all true, 2 = somewhat true, 3 =true, 4 = very true.

NT - 1

ST - 2

T - 3

VT - 4

13

If at any time I feel the coaching relationship is not working for me, I will share this with my coach and work toward a mutually acceptable solution.* This field is required.1 = not at all true, 2 = somewhat true, 3 =true, 4 = very true.

NT - 1

ST - 2

T - 3

VT - 4

14

I have sufficient funds to invest in the coaching, and see coaching as an investment in my personal and/or professional future.* This field is required.1 = not at all true, 2 = somewhat true, 3 =true, 4 = very true.

NT - 1

ST - 2

T - 3

VT - 4

15

I do not have any depression, anxiety or other mental illness or other issue that would interfere with my ability to be coached.* This field is required.1 = not at all true, 2 = somewhat true, 3 =true, 4 = very true.

NT - 1

ST - 2

T - 3

VT - 4

16

Sponsor / Parent NameFor clients under the age of 18 years or clients being sponsored by an organization or company.

17

Please Initial:* This field is required.

18

First session of coaching is FREE to all new clients. Type NEW in the box below if this is your first time with us. Or NA if not applicable.A fee will be charged for additional sessions. This will be agreed upon in your first consultation.