Coaching

Are you working with a professional therapist, counsellor or coach at this time?*

If you have worked with a professional, how long ago?*

More than 12 months ago
Ongoing
For less than 3 months
More than 3 years ago

Are you experiencing a painful conflict or difficult situation in your work or life?*

Painful Conflict
Difficult Relationship
Business/Career Challenges

On a scale of 1 to 10 (1 being low and 10 being very high) how much fear or anxiety is this causing you?*

1-3
4-6
7-8
8-10

Are you seeking ways to grow or improve a relationship with*

Money
Family
Intimate Partner
Change or Renegotiate work relationship
Work or Career

Do you need help setting goals to improve how well you are acting or experiencing an aspect of your business, personal or professional life in the next 3 to 6 months?*

Yes
No
Yes for 12 months
Other

Are you seeking help to design your ideal business or personal wellness lifestyle?*

Yes
No

Do you need to take action to improve how well you experience your life, career or business right now?*

Yes
No
In the next 6 months

Do you want to make more meaningful choices to simplify your life and improve your wellness?*

Yes
No

Are you challenged with making decisions to move forward in a healthy way?*

Yes
No

Do you need to set boundaries in a personal or professional relationship?*

Yes
No

Are you willing to work with someone towards achieving how well you are experiencing your life?*

Yes
No

Do you want to free up energy, or reduce stress at home or work?*

Yes
No

Are you searching for strategies to change how you relate to your family members or friends?*

Yes
No

Are you in a transitioning stage in your life; such as divorcing, remarriage, a new relationship, or wanting to start over?*

Yes
No

Do you need support, partnering, or a sounding board to help you make a life changing decision?*

Yes
No

Do you need help coming to agreements, collaborating, building consensus, or making decisions at work or at home?*

Yes
No

What do you desire in a coach or thinking partnership?*

For clarity and focus
To not feel alone
To gain perspective
To celebrate my success
To gain accountability

If you did nothing about how you are living, working or playing out your life, what will be different in the next 6 months*

Nothing
Things will be better
I won't be able to go on
It will be worse

May we call you to propose a coaching session? If so, what times are best for you?*

Yes
No

Name*

First Last

Phone

Email

Coaching

How Will Working With A Coach Benefit Me?

Coaching