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Initial Intake Form
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General Info
Name
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Your answer
Email
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Your answer
1. How do you rate your current state?
Pls give the following areas in your life points from 1-10.
10= fully satisfied, best state possible
1= not satisfied
General Happiness
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1
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3
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5
6
7
8
9
10
Perceived satisfaction at work
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1
2
3
4
5
6
7
8
9
10
Fulfilling relationships/friends/partner/family
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1
2
3
4
5
6
7
8
9
10
Health
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1
2
3
4
5
6
7
8
9
10
Energy Levels
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1
2
3
4
5
6
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8
9
10
2. Your goals. What would you like most to accomplish when working with us? Do you have specific goals you wish to accomplish? Please state them.
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Your answer
3. Which areas in your life do you wish to see improvement in first.
Please add the priority (1-5)
Work/Success
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1
2
3
4
5
Financial Abundance/Wealth
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1
2
3
4
5
Family/relationships
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1
2
3
4
5
Health
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1
2
3
4
5
Energy Levels/ General Health/ Satisfaction
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1
2
3
4
5
4. What's your why? What do you see as your greatest drive? Do you have a specific passion/mission you feel strongly about? Why do you want to achieve this goal? What will it give you once you achieve it? How would it feel to have achieved this?
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Your answer
5. What is currently holding you back from achieving this? Do you know if and where you are sabotaging yourself?
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Your answer
6. Why do you believe you are not being successful?
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Your answer
7. What do you need to believe in order to make this (your goals, dreams) happen?
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Your answer
8. Imagine for a moment that The Magic Fairy Godmother comes to you and asks you for your one biggest wishes? What would you say?…or in other words: Assuming there were no limitations: What do you really want?
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Your answer
9. Why do you believe this is out of your reach?
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Your answer
10. What is most important to you in life?
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Your answer
11. What is the least important area of your life right now?
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Your answer
12. Why now?
Why are you now going for it, wanting to change and grow?
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Your answer
Why have you chosen us to help you?
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Your answer
What do you expect from us?
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Your answer
What do you need us to know?
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Your answer
13. How committed are you?
How much are you willing to give it/our work together all you have? (rate from 1-10; 1=unlikely; 10=highly likely/certain)
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1
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10
How likely do you think you are to make powerful but possibly uncomfortable decisions 1-10
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1
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10
How likely are you to act upon your choices and carry through what you have set out to do 1-10
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1
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10
Fear of failure often prevents me from taking action 1-10
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1
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10
14. What is your greatest goal you wish to have achieved 1 year from now? What is different? What has changed? How are you different?
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Your answer
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