1:1 Coaching Application
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 email your responses to me before our call.
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Email *
Your Full Name: *
Phone Number *
Street Address *
City *
State *
Zip Code *
Country *
Shirt Size *
Date of Birth:
MM
/
DD
/
YYYY
Gender:
Clear selection
Marriage Status:
Clear selection
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 10 (highest):
Clarity: Do you feel you are clear about who you are, your purpose, and the direction you want togo in life? *
Lowest
Highest
Energy: Do you consistently have enough mental and physical energy needed to excel, accomplish your goals, and feel motivated and happy? *
Lowest
Highest
Courage: Do you take action and consistently express who you truly are and what you truly think, need, and desire with the world? *
Lowest
Highest
Productivity: Are you consistently focused and effective, and are you good at minimizing distractions and maintaining priorities? *
Lowest
Highest
Influence: Do you feel you have the social influence with your family, friends, and team needed to accomplish your goals? *
Lowest
Highest
1. What do you do for a living, and why did you choose that career? *
2. What are your top 3 goals you are striving to achieve right now? *
3. What major stressors or challenges are you struggling with right now? *
4. When you feel like your most successful and happy self, what makes you feel that way? *
5. What would your dream life look like if you could wave a wand and make it happen? *
6. What else has prevented you from having that dream life? *
7. What goal or dream have you ever given up on or failed at, and what do you believe caused you to stop or fail? *
8. What 3 big changes would you like to make in your life in the next 12 months? *
9. What are you most proud of and excited about in your life? *
10. What negative recurring thoughts, fears, or behaviors would you like to overcome in order to feel more psychologically free, confident and successful? *
11. What eating, exercise or general health habits would you like to begin or break in order to feel stronger and more healthy physiologically? *
12. What distracts you the most from being more productive, and what major projects or missions are you struggling to complete faster or more efficiently? *
13. If you were more persuasive or influential, what dream or desire would you ask others to support you in achieving? *
14. When do you struggle to be fully present in your day or in any of your relationships? *
15. How purposeful do you feel in living each day, and how would you describe your purpose? *
16. Why would you like to work with a high performance coach? *
17. Why do you feel you could be a great student or coaching client if we worked together? *
18. How would your best friend describe you? *
A copy of your responses will be emailed to the address you provided.
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