Questionnaire for your Coaching Strategy Session
Goal: To help you reach heightened levels of clarity, energy, courage, productivity, and influence on your march to a successful, healthy, and fully charged life.

Instructions:
Please answer the questions below and on the following pages to the best of your ability and submit. I will go through your form and based on your responses i will email you with the outcome. Please NOTE that I reserve the right to not respond to not offer you a session especially if your form is not fully completed or if I feel the help you need will be from a different type of coach or professional. In most cases I contact everyone who has taken their time to share with me. so don't worry if you are committed to moving forward, i will be committed to working with you too.

Source: This tool is based on proprietary concepts from High Performance Institute's Certified High Performance Coaching Program™. Do not duplicate or distribute without permission.

Email address
I honour you for your commitment to self improvement and High Performance and I will be happy to help you to the best of my ability. Please complete the form and submit. It will reach me directly and in confidence. Thank you. Amina Chitembo, Your Certified High-Performance Coaching Expert.
FIRSTNAME:
LASTNAME:
Date of Birth
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Phone Number (include Code):
Address1:
Address2:
Town/City:
County/State:
Post/ZIP Code:
Occupation/Industry (inc. Stay at Home/Student)
Position/Level
Gender
Marital Status
Please briefly describe how you heard about my coaching services and why you would like a Strategy Session with me:
Please rate yourself in the following areas of your life on a scale of 1 (lowest) to 5 (highest):
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2
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5
CLARITY: Do you feel you are clear about who you are, your purpose, and the direction you want to go in life?
ENERGY: Do you consistently have enough mental and physical energy needed to excel, accomplish your goals, and feel motivated and happy?
COURAGE: Do you take action and consistently express who you truly are and what you truly think, need, and desire with the world?
PRODUCTIVITY: Are you consistently focused and effective, and are you good at minimizing distractions and maintaining priorities?
INFLUENCE: Do you feel you have the social influence with your family, friends, and team needed to accomplish your goals?
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