Intake Form
To understand and fulfill the individual needs of every client, we are requesting that you complete the following questionnaire. Please, be as specific as possible so that our services can be tailored to your priorities.
Date:
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Name: *
Your answer
Address:
Your answer
Work Phone:
Your answer
Home Phone: *
Your answer
Fax Number:
Your answer
E-Mail Address: *
Your answer
Marital Status:
Birthdate:
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Education: *
1. Briefly describe your current state of mind: (sad, awesome, angry, feel great, frustrated, happy, mad, confident etc) please be specific and as detailed as possible. *
Your answer
2. How did you get into this state of mind?
3. Why are you paying so much attention to your situation now?
Your answer
4. Are there any known issues causing unrest? If so, what are they?
Your answer
5. On a scale of 1 to 5 where 1 is very low and 5 is very high, how much of your desire for a change in attitude is motivated by the desire to know your focus from now on?
Very low
Very high
6. Habitually what makes you proud?
Your answer
7. What would be the key characteristics of an ideal end of day for you?
Your answer
8. What are your strongest talents? (Please explain) Put 3 to 5 *
Your answer
9. What are your weak areas? (Please explain) Put 3 to 5 *
Your answer
10. What hobbies do you have? Put up to 6 *
Your answer
11. What other skills and interests do you have?
Your answer
12. Community Involvement:
Your answer
13. If you received a 10 Million-Dollar inheritance tomorrow, what would you do? How would your life change?
Your answer
14. If the doctor told you today you had 6 months to live, what would you do in those remaining months?
Your answer
15. What are you doing in your life now that will last forever?
Your answer
16. In writing your epitaph, what would you want people to remember about you?
Your answer
17. What are your expectations for Life Coaching? Put 3 to 5 entries.
Your answer
18. What are your concerns or fears in dealing with a consultant?
Your answer
19. This is a process of LIFE PLANNING. This can be a time of stress, frustration, and uncertainty, but also excitement, wonderment, and positive anticipation. What can we do to make this experience more enjoyable? List three to five things. Put 3 to 5.
Your answer
20. Who referred you to Act On Your Dream Today?
Your answer
Our mission at Act On Your Dream Today is to foster the process of imagining, dreaming and introspection to help people in the process of increasing their confidence and positioning themselves as leaders in their fields, and to translate that into meaningful, purposeful and tangible results in their life, career, and inner-self. To provide hope and encouragement that embracing one’s dreams is the most practical way to bring forth our unique potential and to become an asset in the field of our choosing.Position yourself (ask for concrete value) where you want to be. Although some questions are optional, we highly recommend you answer all of them as they give your coach more clarity on the scope of work.
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