Initial Assessment Form

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Answer the following questions to the best of your ability. Feel free to skip any questions that aren't applicable or that you'd prefer not to answer.

Email *

Privacy Statement:
Your privacy is of the utmost importance to me. I am committed to ensuring that all information you share during our coaching sessions is kept strictly confidential. This means that:
Confidentiality: All personal, professional, and sensitive information you disclose during coaching will remain confidential and will not be shared with any third parties without your explicit consent, unless required by law (such as in cases of harm to yourself or others).
Record Keeping: Any notes or records from our sessions will be securely stored and accessible only by me. These records will be used solely for the purpose of improving your coaching experience and tracking progress.
Exceptions: Confidentiality may be broken in exceptional circumstances if there is reason to believe that you are at serious risk of harm or if there is a legal requirement to disclose information (e.g., court order). In such cases, I will make every effort to inform you prior to any disclosure.
By working with me, you can trust that your privacy and confidentiality are my top priority. I am dedicated to creating a safe, supportive, and private environment for your personal growth and success. *

I acknowledge

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First Name *

Last Name *

Phone Number *

How did you hear about me? If referred by someone please list their name here.

In a few words, describe the reason you want to work with a life coach?
Is there a goal you want to achieve that you haven't been able to? Is there a realization you've had that you want to take action on? Is there a feeling you have that you want to change or an experience you wish you could be having?

Do you know what you want out of life?

Yes, absolutely and I'm on the right track!

No, I feel kind of directionless.

I know some things that I want, but I feel like I could be more focused.

Yes, but I don't know how to achieve it.

I'd like to think about this some more.

If you could make one small change about yourself or your life today, what would it be and why?

When you think of the future, how do you feel? Select all that apply.

Excited

Hopeful

Uncertain

Motivated

Anxious

Overwhelmed

Confident

Curious

Fearful

Determined

Think of your most perfect, ideal life and compare it to your current life. What are the big differences? What is missing currently?

Compared to other people, would you say that you're a happy person overall?

Yes, most of the time!

I'm a slightly above average happy person.

Half and half.

Other people seem to be happier than me, more often than not.

I don't think that I'm a happy person.

Clear selection

Do you feel like you have strong, good quality friendships?

Absolutely

Eh, more or less

Half and half

Kind of, but not really

Not at all

Clear selection

On a scale from 1 to 10, how well do you feel understood by other people?

Not at all

Very well

Clear selection

In the past week or month have you experienced feelings or thoughts that you wish would just go away? If so, please describe your experience.

In a few words, what do you think is the biggest barrier to your happiness right now?

Do you love yourself as you are?

Yes

Half and half

Clear selection

Do you feel like you have a good sense of who you are as a person?

I don’t know who I am

I strongly know who I am

Clear selection

A copy of your responses will be emailed to the address you provided.

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