Executive CoachingIntake Form Name First Name Last Name Email Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Marital Status Occupation Length of time at this occupation How do you prefer to read Hard Copy Kindle Audio Other What is your favorite restaurant? What is your favorite sweet treat? What do you like to do in your free time? What is your favorite "puts me in a joyful mood" song? Goals What are the three biggest changes you are committed to make in your life in the next 3 months? What are the top three things holding you back from achieving those goals or areas of growth/change? What would you say have been your 3 greatest accomplishments to date? What is the hardest thing in your life that you have had to overcome? Have you worked with a coach before? If yes, what worked well for you and what did not work in the relationship(s)? What major transitions have you had in the past two years? (Example: Entering or approaching a different age, a new or different relationship, job, role, residence; A change in children’s ages/stages, etc.) Your Life Who are the key people in your life and what do they provide for you? On a scale of 1 to 10, with 10 being high, rate the amount of stress in your life right now: What are your primary stressors? List five things that you are tolerating or putting up with in your life at present. (Examples: information you can’t find, clutter, rude friends, poor lighting, tight shoes, dented car, job dissatisfaction, dead plants, broken equipment, old appliances, etc.) Yourself List 5 words that describe you at your best. What motivates you? What takes away your motivation? What are you learning about your life? On a scale of 1 to 10 with 10 high, rate the quality of your life today. If known, please list your top 5 strengths from Gallup StrengthsFinder, your Myers Briggs Type Indicator, and Enneagram If you reach the age of 95 and continue to live your life and order your time the way you are right now, what regrets do you think you will have? (Tip: complete the statement “I wish I had…”) Do not include things from the past—only things you will regret if you continue your exact present path. What types of approaches discourage you or take away motivation from growth? Any additional comments: Thank you for taking the time to fill out this intake form. It will help prime the pump for your vision coaching conversation with me! Looking forward to our time togetherTim
