Name

Age

Email Address

Address

State/Province

Date Of Birth

Date Of Loss

Gender Gender Female Male Other

Behaviour: Behaviour: Change in appetite Insomnia Withdrawal Phobic avoidance Lack of motivation Suicidal attempts Outbursts of temper Crying Use of alcohol Implusive reactions Concentration difficulty Aggressive behaviour Loss of control Use of substances

Feelings: Feelings: Angry Conflicted Energetic Sad Panicky Depressed Guilty Restless Fearful Regretful Relaxed Unhappy Irritated Frustrated Tense Anxious Lonely Bored Helpless

Physical: Physical: Headaches Fatigue Dizziness Dry mouth Tension Rapid heartbeat Numbness Unable to relax Fainting Tingling Sweating Sexual disturbance Stomach trouble Palpitation Hot/cold flushes Bowel disturbance

Please indicate any other symptoms or behaviours that may be relevant to your current situation:

What are you wanting to change or improve now?

Why are you seeking change now?

How will you know when you have achieved what you want?

What in your current situation upsets you the most? How do you know you are upset?

What is most important to you in your life and how do you know that?

What are you major concerns and why?

List your top five values:

What is your personal vision?

What are you primary business/professional goals?

List your five goals you have currently? (Now Vision):

List five goals you want to accomplish within the next 12 months? (Near Vision):

List five goals you want to accomplish in your lifetime? (Far Vision):

What are your professional strengths and assets?

What is standing in the way of holding you back?

What accomplishments are you most proud of in your life and why?

What do you want to get out of our coaching relationship

How did you know if you are getting it?

Comments: (Please note any other issues that are important for me to understand as your coach, eg. physical, psychological, belief issues)