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Coaching Intake Form
THE OPEN MIND INSTITUTE
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* Indicates required question
Email
*
Your email
Full Name:
*
Your answer
D.O.B
MM
/
DD
/
YYYY
City/ Place of Residence:
*
Your answer
Mobile Phone:
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Your answer
Occupation:
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Your answer
What life areas, if any, would like to improve (i.e. health, relationships, career, time management, self-management)?
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Your answer
What are your strengths or positive attributes?
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Your answer
What is the biggest limiting behaviour or habit (if any) that is causing you the most concern?
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Your answer
On a scale between 1-10: How would you rate your
mental-wellbeing
(your general state of feeling comfortable, healthy and happy)?
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Poor
1
2
3
4
5
6
7
8
9
10
Extremely Positive
How would you rate your level of
self-awareness
(being aware in the moment of your inner-voice, emotions, behaviours and how they impact your life, and others)?
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Limited
1
2
3
4
5
6
7
8
9
10
Exceptional
When challenged, how would you rate your ability to use a
growth mindset
(adopting an attitude that you'll be able to navigate, overcome or at least grow from the experience)?
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Never
1
2
3
4
5
6
7
8
9
10
Most to all of the time
How would you rate your
overall performanc
e (includes things like your energy level, ability to positively engage with others and to achieve desired outcomes)?
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Poor
1
2
3
4
5
6
7
8
9
10
Extremely Positive
How would you rate your general motivational level?
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Not very motivated
1
2
3
4
5
Very Motivated
Have you seen or are you seeing a psychologist, psychiatrist or other mental health professional (and if you feel comfortable elaborating, what was this in relation to?)?
*
Your answer
Any additional information you wish to provide:
Your answer
Thank you!
We will be in contact with you shortly. For any questions please email us at
info@tomi.org.au
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