Coaching Form

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Coaching Form

Email *

Last Name *

First Name *

Email Address *

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Address *

Phone Number *

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Race/Ethnicity *

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Black/African-American, Non-Hispanic

Hispanic, Latino, Spanish Origin

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Gender *

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Hobbies? *

Relationship Status *

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Divorced

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List the names/ages of all the members of your current immediate/nuclear family and describe them.

List the names/ages of your extended family and describe them.

List any important information about your life/family such as major life adjustments, health issues, traumas, or unusual circumstances

Describe what you would like to accomplish with coaching. Goals?

Have you attempted before now to reach these goals?

Yes

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What is getting in the way of having these goals met?

Any other agencies that have helped you with coaching?

What are you passionate about? What makes you feel alive?

What is missing in your life in order to have a "successful and satisfied life?"

Why start coaching now?

What things do you tend to procrastinate about?

How would you like to be held accountable or supported?

How will you know how effective your coaching sessions will be?

What else would you like me to know?

What does fulfillment in life look like to you? What would you like to change or not change in your life? Consider the following areas of life and ask yourself, “How satisfied am I in this area?” There is may be room to grow and develop in every area, but what stands out as needing some time, attention, and intention? What would make the biggest impact on your life if it were to improve? Rate each area on a scale from 1 – 10. If you give an item a 1, you are completely dissatisfied with this part of your life. It means, “This part of my life is entirely unacceptable to me in its current state.” A number 10 means “I couldn’t be happier or more satisfied with this area of life.” Your overall satisfaction will change from day to day, but try to give an overall assessment of where you are at present.

Physical Health

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Mental/Emotional Health/Attitude

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Career/Employment Satisfaction

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Financial Stability

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Marriage/Romantic Relationships

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Home Life (immediate family)

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Extended Family

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Friends/Social Life

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Recreation/Relaxation/Leisure

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Lifestyle

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Personal Life Fullfilment

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Spiritual and/or Religious Health Life

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Physical Comfort

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Emergency Contact *

Referred By? *

Religious Preferences *

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