SECTION A

Please consider the following areas of your life.

Please rate on a scale from 1 to 10 how satisfied you are with each of the areas. 1 being totally dissatisfied and 10 being totally satisfied.

                                   Health: 
                                   Family:
                                  Career:
                 Financial Wellbeing:
Friendships and Social Support:
                 Spiritual Alignment:
           Romance and Intimacy:
            Quality Personal Time:  
                Fun and Recreation: 
             Physical Environment: 



SECTION B

Which one zone best describes your current situation.

PAIN ZONE:
You are suffering. You are mostly in pain. Some of your most basic needs are not being met. You are paralyzed or stuck. You know you are living a life or working in a career that is not right for you. You feel heavy and sluggish. You are hurting deep inside. You feel helpless or hopeless. Each day is a struggle for you.

COMFORT ZONE:
You are drifting. You are mostly comfortable. Most of your immediate needs are being met. You have settled into unconscious habits and routines. You have lost your passion and excitement for life. Your decisions are mostly based on responsibilities and the expectations of others. You are deferring personal responsibility. You have lost touch with who you are and what you want from life. You are selling yourself short. You are settling for less. You are missing a depth and richness in your life. You are beginning to feel lost.

HAPPY ZONE:
You are awake. You are mostly happy. You are in awe of life and all the riches it has to offer. Your life honors and reflects your values. You make conscious choices regarding the quality and direction of your life. Life excites you. Life energy flows through you. You challenge yourself. You exercise your imagination. You feel light. You smile, grin and laugh alot. You make a difference in the lives of others. You seek velocity and scope for your success. You seek fulfillment.



SECTION C

Please check the statements that apply to you.

I want to make positive changes in my life.
I have so much more to give.
I am ready to take responsibilty for my choices.
I am willing to be open and honest with myself.
I want to move forward.
I know I can improve my life.
I deserve more.
I am ready to take action.
I recognise my need for help and support.
I am ready to commit to the coaching process.



SECTION D

Please answer the following questions in your own words:

1. What would you like to address with your Life Coach in your very first session should you choose to proceed?:


2. What do you hope to gain from hiring a Life Coach should you choose to proceed?:


3. Is there anything else you would like your Life Coach to know prior to your first coaching session?:


SECTION E

Finally, please fill in your personal details. 
Information is kept private, confidential and is NEVER shared.

                YOUR NAME:

YOUR EMAIL ADDRESS: