Name
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First Name
Last Name
Email
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Phone
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Age
Gender
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Relationship Status
Children (if so, ages)
Occupation
Vitality
Connection
Meaning
What do you most want to get from the coaching relationship?
What is the best way for me to coach you most effectively? What tips would you give me about how you operate?
What are your apprehensions or preconceived ideas of coaching?
What are 3 things you'd like me to know about you?
How did you hear about my work?
Please describe your lifestyle and what you do to support your wellbeing.
Stress: I am able to cope with my current stress load.
What are some of the most relevant stressors in your life right now? How do you typically react to/cope with them?
What do you do when you are really up against the wall?
Mark any symptoms that apply to you.
During the past 4 weeks, to what extent have you accomplished less than you would like in your life, as a result of emotional issues (e.g., feeling depressed or anxious)?
Sleep: I get 7-8 hours of uninterrupted sleep every night.
What contributes to your sleeping well/poorly, respectively?
Energy: I have a zest for life and energy throughout the day.
What depletes you? What energizes you?
Mindset: I am aware of my thoughts and actions and typically feel nonjudgmental towards myself.
Do you practice meditation? If not, are you open to it?
Nutrition: My diet is exactly where I want it.
Describe a current typical week of food and beverages. What do you know to eat more of and what do you know to reduce intake or avoid? What are your biggest challenges with eating a nutrient-dense diet?
Physical Fitness: I feel strong, flexible, and in shape. I am happy with my physical condition.
Describe a current typical week of physical activity. What is your ideal amount? What are your biggest challenges to your ideal?
Recommended physical activity guidelines include:
A. Resistance: Moderate- or high-intensity muscle strengthening/endurance/agility activities that involve all major muscle groups 2+ days/week
B. Flexibility: Static or dynamic stretching of all major muscle tendon groups (4+ repetitions/group) 2+ days/week
C. Cardiorespiratory: At least 20 minutes of vigorous aerobic activity 3+ days/week (hard enough to make you breath heavily or make your heart beat faster) OR 30 minutes of moderately intense aerobic activity 5+ days/week
Body Image: When I look in the mirror, I feel content and grateful for the body I have.
How does body image influence your self-worth? What triggers inner criticism? What can you acknowledge that is positive about your body?
Alcohol (or other substance): I have a healthy relationship to alcohol/substance use.
Tobacco
Mark the appropriate response.
What is the role of alcohol/tobacco/other substance in your life? How much (if any) do you consume? What benefit do you get from drinking? What is the cost?
Finances: The amount of money I have gives me feelings of security and freedom.
What is your relationship to money? How does money influence your wellbeing?
Relationship/ Romance: I am fulfilled by my current relationship status.
What do you like most about your current relationship status? What challenges are you experiencing?
Friends: I have people in my life whom I trust with my problems, care about, have fun with, and can be myself around.
How often do you get together/ talk with friends? How do they support you? How do they challenge you?
Family: I love and respect my family, and I know they love and respect me.
What role(s) do you play in your family? How does your family contribute to your wellbeing? In what ways do they contribute to your distress?
Physical Environment: I am happy with my home and my community.
How organized and supportive are your "spaces"? How does your environment influence your life?
Self-Care: I regularly take "me time" to support myself.
What do you do to take care of yourself (massage, alone time, music, art, sauna, etc.)? And what do you wish you did more of?
Play: I know how to "play" and enjoy myself.
What activities are fun for you? Do you have any hobbies or special interests? How do you "get away"?
What makes you come alive?
What’s missing in your life, the presence of which would make your life be more fulfilling?
What is (or might there be) a secret passion in your life? Something you may or may not have allowed yourself to do so far, but which you would really love to do.
What unique gift or knowledge do you have to contribute?
What accomplishments or events must, in your opinion, occur during your lifetime to consider your life satisfying and well lived?
Career: The work I do harnesses my strengths and experience. It suits me well.
What personal strengths do you use in your career? What challenges are you currently experiencing? How does your career influence your wellbeing?
Personal Growth: I am always learning new things and developing as a person.
How have you evolved as a person over the last year? What are you currently engaged in that feels purposeful? What role does spirituality play in your life?
General Health
Complete the following statement: In general, my overall health is...
Please describe any health challenges you currently experience (major concerns, as well as just bothersome things like headaches, insomnia, etc. within the last 4 weeks).
Pain: My bodymind feels good most of the time and I rarely hurt.
What is/are your greatest source(s) of physical/emotional/mental pain? What seems to trigger it/them? What relieves it/them?
Physician Relationship
Do you have a primary care doctor whom you trust and see regularly?
Physical Exam
When was your last physical examination? Within the last...
Women's Health
Mark all that apply.
Medications
How often do you use drugs or medicines (including prescription and nonprescription) that treat depression, affect your mood, help you relax, or help you sleep?
If applicable, what is/are the name(s) and intended impact of the medication(s)?
Health Limitations
During the past 4 weeks, how much difficulty did you have doing regular activities as a result of your personal health?
Family Health History (please list any problems experienced by members of your immediate family)
Is there anything else you'd like to tell me before our session?
Reflecting upon all you've shared here, what two steps could you take immediately that would make the greatest positive impact?