Coaching Pre-Work
This questionnaire will serve as an opportunity for me to get to know you better and to help make our time together as effective and supportive as it can possibly be. Please read the following questions carefully and answer them thoughtfully. Please feel free to answer as honestly as possible; your responses are kept strictly confidential!

If you have any questions please email Gretchen at support@koelleinstitute.com
Email address *
First and Last Name *
Phone Number *
General Information
What sparked your decision to seek out support? *
Please feel free to share whatever you feel comfortable expressing about your childhood upbringing. How do you currently feel about it? What is your relationship with each of your parents (or grandparents, caretakers) like? *
How do you tend to spend most of your days? Do you work? Are you a student in school? Are you a stay at home parent? On a scale of 1 to 10 how fulfilled do you feel by the work that you do or how you spend most of your time? Please explain. *
If you are currently in a romantic relationship (dating, married, divorced, etc.) please describe this relationship from your perspective and how you feel about it.
If you are currently single please share a little bit on how you feel about it.
What are 3 events or experiences that have been happening in your current life that you are enjoying? *
What are 3 events or experiences that have been happening in your current life that you feel are stressful or that are challenging you? *
Have you had any traumatic experiences that you would like me to know about (ie. sexual abuse, physical abuse, verbal abuse, witnessing traumatic events, etc.) Please only write what you feel comfortable sharing. If you would rather not say it’s completely okay to leave this blank.
Have you been having any health challenges that you would like me to be aware of?
Can you describe 3 names or situations whom you have the most difficult time communicating with and explain from your perspective why you think this is the case? *
Additional Information
Do you have any additional concerns or questions?
Is there anything further you would like to mention here that you feel is relevant?
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