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    Name *

    Phone *

    Email *

    City *

    State *

    Web Page

    What occupation or business are you in?*

    Where did you first learn about me? *

    Did someone in particular refer you? If you received a Gift Certificate, please enter GC + the name of the person who gave it to you.

    Vision*

    What’s your vision for your life? What would you be enthusiastic, ecstatic, thrilled to create in your career or business in 1-3 years?

    Positive Impact*

    What impact do you want to have in the world? What positive difference do you want to make?

    Ideal Life* *

    If you had your ideal life, what would that look like? Career? Fun? Relationships? Community? Money? Home environment? Personal or spiritual development? Health and well-being?

    Why?*

    How would achieving your vision improve your life? What would be the best part? Why is this important to you?

    Feelings?*

    How do you imagine it would feel to achieve your vision? Please provide at least three adjectives to describe your feelings.

    Obstacles*

    What holds you back from achieving your vision? What are you biggest obstacles?

    On a scale of 1-10 (1=low, 10=high), how would you honestly rate yourself in these 10 key areas of life success:

    Compelling Vision*

    I have a clear and compelling vision that pulls me forward.
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    Committed and Engaged*

    I am fully “committed” and “engaged” with achieving my vision.
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    Being*

    I am consistently “being” my most magnificent and powerful self, the person I need to be in order to achieve my vision.
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    Obstacles*

    I am clear about my specific obstacles/challenges and I have a plan to triumph over each one.
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    Goals, Strategy, and Action Plan *

    I have written measurable goals, milestones, strategies, and a good action plan.
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    Self Care*

    I know what maintains my optimal well-being and implement that consistently.
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    Time Management and Organization *

    My time management and organization is excellent.
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    Action and Follow Through *

    My follow through is consistent. I am taking massive action.
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    Celebration *

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    Support *

    I celebrate my achievements and my efforts regularly.
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    Have you ever worked with a career or life coach before? *

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    On a scale of 1-10, how motivated and committed are you to achieve these results?*

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    On a scale of 1-10, how motivated are you to find and enroll in the right coaching program for you? *

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    What concerns, if any, do you have about coaching?