Date of Birth *
Street Address *
City *
State *
Zip Code *
Phone Number *
Email *
Best for of Contact * Phone Call Text Message E-Mail
Where do you work? *
How long have you worked there? *
What is your Position Title? *
Description of your Job *
1. What matters most in your Life? (Ex. What are your top 5 priorities in your life, and in what order?) *
2. Why do these things matter to you, and how does it strengthen you? *
3. What is your Daily Routine? *
4. What are your biggest strengths? *
5. What are your biggest weaknesses? *
6. Which of your strengths becomes your limitation when you exercise it too much? *
7. What is your ultimate goal in life? How do you want to leave your Legacy? *
8. What makes you different from others? *
9. How would your best friends describe you? *
10. What do you not want to be asked? *
11. What is the current biggest challenge(s) that you are facing? *
12. What do you need the most right now? *
13. What is the Definition of Success from your Viewpoint? *
14. What is something that you are proud of? *
15. Who are the Key People in your Network of Support? *
17. What is standing in your way? *
18. What is a major obstacle or event you have faced, and what did you learn from them? *
19. What advice would you give to someone who was in a similar situation? *
20. If things go exactly the way you want in the next 6 months, what would you see? *
21. If three of your wishes came true right now, what would they be? *
22. Where would you like to see yourself overall in the next 5, 10, 15, or even 20 years out? (This can be answered in anyway, whether it is about something specific, or in general.) *
2a. Is there any further information you would like to share about your work place environment? *
4a. Is there any further information you would like to share about your home environment? *
1b. This is your opportunity to share any details about relationships with family, friends, personal, professional, significant others, etc. This can be positive, negative, or neutral aspects. *
1c. Tell me about your sleeping habits over the last 3-6 months. Have you noticed any changes? Difficulty sleeping? Restlessness? *
2c. How would you describe your energy over the last 3-6 months? *
3c. How would you describe your ability to focus over the last 3-6 months? *
4c. Has there been any times over the past few months that you’ve been bothered by low feelings, stress or sadness? If so, when and why? *
5c. How frequently have you had little pleasure or interest in activities you usually enjoy? *
6c. Do you feel there are any important questions that have not been asked? *
7c. How often during the past several months have you dealt as though your moods, or your life, were not under your control? *
8c. How frequently have you been bothered by not being able to stop worrying? *
9c. Tell us about how confident you have been feeling in your capabilities recently? *
10c. How often have you felt satisfied with yourself over the past several months? *
11c. How often over the past several weeks have you felt the future was bleak? *
12c. Can you tell us about your hopes and dreams for the future? What feelings have you had recently about working toward those goals? *
13c. Describe how supported you feel by others around you? (Ex. Friends, family, or otherwise) *
14c. Tell us about any important activities or projects that you’ve been involved with recently, how much enjoyment do you get from these? *
15c. How frequently have you been doing things that mean something to you or your life? *
16c. How bothered have you felt about tiredness or low energy over the past two weeks? *
17c. How bothered have you felt about thoughts that you’ve let yourself or others down? *
18c. Over the last two weeks, how bothered have you been by feeling fear or dread, as though something terrible might happen? *
19c. How often have you been bothered by so much restless that you can’t sit still? *
20c. How often do you feel fidgety or unable to sit still? *
1d. What would be an inspiring future for you to work towards? *
2d. If you got everything you wanted, how would your life look a year from now? *
3d. Would you like to explore this dream and see if it’s a real possibility? *
4d. What does your ideal life look like in five years? Describe it in detail, including your personal and professional accomplishments. *
5d. How would you like to grow and develop as an individual in the next year? *
6d. What steps can you take to make your dream career a reality? *
7d. How can you maintain a healthy work-life balance while pursuing your goals? *
8d. If you woke up tomorrow, and a miracle happened, what would be the first think you’d notice that would tell you your life has changed for the better? *
9d. Imagine you have achieved all your goals and dreams. What does your life look like in this new reality? How do you feel? *
10d. If all obstacles were removed, what would be the one thing you’d love to accomplish or experience in your life? *
11d. Close your eyes and envision your perfect day—what does it consist of, and how are you spending your time? *
12d. What would you like your legacy to be, and how can you start building it today? *
1e. What would be an inspiring goal, or series of goals for you to work toward? (Please list then from highest priority to lowest priority). *
2e. What do you specifically want to accomplish? *
3e. How could you rephrase that goal, so it depends only on what you do and not on others? *
4e. How will your life change because of working on this, or these goals? *
5e. How would you make your goal more measurable so that it’s clear when you’ve achieved it? *
6e. By when do you want to complete these goals? *
1f. Where are you today in relation to your goals? *
2f. What have you already accomplished? *
3f. What have you tried that worked/didn’t work? *
4f. What events and decisions led you here? *
5f. Who else is involved in this situation and how? *
6f. Are you okay with us focusing on one key goal at a time, unless otherwise necessary to focus on multiple? If so, which would you like us to start with? *
1g. What are some options you have in working towards these goals? *
2g. Take a moment to reflect, and see if you can come up with another 5 options to move forward with your goal? (No option is too big, or too small) *
3g. If you had unlimited time and money wasn’t an issue, what would you do? *
4g. Is there anyone in your life, or that you wish you were connected with, that you feel could give you more clarity, or help you to achieve these goals? *
5g. What have you seen others do that might work for you? *
1h. Which options do you want to act on? *
2h. How can we turn that into an actionable task? *
3h. What’s the first step you want to commit to? *
like that the
4h. When would you like to get this next step done by? *
6h. Are there any obstacles we need to address, to make sure this gets done? *