Personal Coaching Assessment Application 
 
By completing and submitting this personal coaching assessment (application) form you will be contacted by a coach to confirm your 1 - 2 hour paid coaching session.  This exercise will also help you assess if coaching is for you. (You will also need to fill out this same form if you are applying for Life Coaching Membership). Please complete all requested information so that we can get in touch with you. Note: "Name" and "Telephone" are required to send this assessment form.
 

1. What one word would you use to describe your life success?: select...Purposeful:Fulfilling:Eventful:Stressful:Conflicted:Other:

If Others, Please explain:

2. How would you rate the following aspects of your life out of 10?
Success: select...12345678910

Family: select...12345678910

Health: select...12345678910

Spirituality: select...12345678910

Happiness: select...12345678910

Finances: select...12345678910

Friends: select...12345678910

Career/Business: select...12345678910

Significant Other: select...12345678910

3. Would you like to work on an area of your life based on your ratings?:

4. If you could change one aspect of your life story right now, what would that be?:

5. What has kept you from changing this area of your life or business? :

6. What emotions, attitudes or behaviour remain constant in your story?: select...Anger:Fear:Envy:Procrastination:Lack of Planning:Impulsiveness:Other:

If Others, Please explain:

7. What are three things that you would like to change about your life in the next 3 - 9 months? These could be life, work or business related:

8. What kinds of changes will this bring to your life and what would you need to do to prepare for the planned and unplanned changes? :

9. If you had a coach, which of the following would be most beneficial to you?:

Thinking Partnership:

Co-creation:

Courage:

Support:

Focus:

Accountability:

Inspiration:

Clarity:

New Ideas:

Other :

If Others, Please explain:

10. If you were to do nothing about the issues in your life, what would change? Would you be happy to have things remain as they are? :

11. Is there someone or something in your life that you are missing out on? Would you like to begin enjoying or appreciating this more? :

12. Would you like to rewrite your life story? What would it look like in 3 months, 6 months, or 1 year from now?:

13. What is your house hold income?:

30,000 - 50,000

50,000 - 100,000

100,000 - 400,000

450,000 and up

14. If you had to pay for coaching monthly, how much could you afford to invest?:

$350 - $400

$500 - $600

$700 - $900

$1000 - $1500

15. Where have you heard about Life Coaching Centre?:

Workplace:

Workshop:

Building Signage:

Referral:

Other:

Complete the following information and we will contact you to arrange an appointment for your interview or coaching orientation.
Name (required): *

Email: *

Telephone (required): *

Best time to call:

Best day/time to schedule interview:

Questions-Comments:

I would like to subscribe to the Centre's Newsletter.: select...YesNo

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