Coaching Questionnaire

Filling out this questionnaire is the first step for your complimentary coaching session. There is no obligation for you to move ahead with coaching. The choice is always yours. We will spend 20-30 minutes on the telephone exploring ways to help you and/or your business excel.

Be assured that all information you provide is completely confidential.

Fields marked with a * are required.

Name *




Zip Code

Name of Business

Type of Business

Your Position or Role

Years in this business

Office Phone Number

Home Phone Number *

Fax Number

Email *

Web Site Address

Referred By

If Other, please specify

Your responses to the following questions will prepare us both for our "get acquainted" complimentary coaching call.

  1. Please rate your clarity regarding both your personal and business vision:

    Personal - check one
    I have no clear vision.
    I have a vague idea of my personal vision.
    I have a fairly clear idea of my personal vision.
    I have a very clear personal vision.

    Business - check one
    The business has no clear vision.
    The vision of the business is vague and could be much clearer.
    We have a fairly clear vision of the business.
    Our business vision is very clear and we operate consistent with it.

Answer the following questions to the best of your ability.

  1. What is your personal vision?

  2. What is the vision of your business?

  3. In 25 words or less, please write your personal purpose.

  4. If you were to work with a life coach, what would you like to change/develop in your life?

  5. What do you want to create or accomplish in the next three to six months?

  6. What would you like to accomplish in the next one to two years?

  7. Have you ever worked with a success coach or have you coached others? Please explain.

  8. What are you putting up with in your life that may be holding you back?

  9. What benefits and/or results do you want to get as a result of being in a coaching relationship?

Setting up our complimentary coaching session

Please enter three different dates and times that you would be available for your complimentary coaching session. Complimentary sessions are 20-30 minutes in length and are generally scheduled Monday through Thursday between 10:00 a.m. and 4 p.m. Pacific time.

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Date (dd/mm/yy)

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Date (dd/mm/yy)

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Thank you! Please submit your responses by clicking the button below. We will contact you within 48 hours to confirm your complimentary coaching session.