Name
Date
Address
Day phone
Evening phone
Email
Briefly describe why you are interested in having life coaching. What goals would you like me to help you achieve?
Please rate the following areas of your life on a scale of 1 to 10, with 1 being very poor and 10 being excellent. 1. Physical Health 2. Emotional Health 3. Relationship (primary) 4. Friendships 5. Spiritual Health 6. Job or career 7. Financial prosperity 8. Sense of purpose 9. Assertive ability 10. Time management
What else would you like me to know about you? Are you in therapy or taking medication? If yes, please explain.
Life Coaching is also about life balance. The skills for creating what you want inone area of life will transfer to other areas. For each of the life areas below, write down what you would like to achieve as specifically as possible. Be as extensive as you’d like. Professional Goals: Financial Goals: Physical (Health) Goals: Relationship Goals: Emotional Goals: Spiritual Goals:
In the past, what has helped you achieve goals you’ve set? What are a few of your strengths? What additional skills do you need to achieve your goals? PHYSICAL HEALTH - Behaviors Put a check mark if the answer is yes
I exercise regularly at activity I enjoy.I eat a healthy, balanced diet.I limit caffeine intakeI do not smokeI know how to relax my bodyI limit my sugar intake.I practice deep breathingMy blood pressure is normalI limit my alcohol intakeI sleep well
Symptoms If you never experience the following symptoms, mark “0.” If you experience them occasionally, mark a “1.” If you experience them frequently, mark a “2.” Cardiovascular: Heart Pounding, Heart racing, Headaches (throbbing), Rapid, shallow breathing, Shortness of breath, Asthma, Upset stomach, Excess gas, Constipation, Diarrhea Muscular: Headaches (steady pain), Neck, back or shoulder pain, Muscle spasms Respiratory Skin, Acne, Dandruff, Excess perspiration Gastrointestinal Immune system, Allergies, Frequent colds, Frequent flu, Skin rash Are there any symptoms you experience that are not listed here? If yes, please write them down.
Are you dealing with any dis-ease? If yes, write it down. Are you receiving any medical care for this dis-ease? If yes, please explain.
