Name:__________________________________________________________________
Address:________________________________________________________________
City: _________________________ State: ___________ Zip: _________
Daytime telephone: _______________________________________________________
Evening telephone: ________________________________________________________
Fax_____________________________________________________
e-mail: __________________________________________________________
This questionnaire is designed to explore your goals and attitudes towards life. The more information you provide, the more effective your sessions will be. Being honest in this questionnaire will help us together, uncover areas of dissatisfaction and concern in your life. These can be identified as follows:
- Tolerances - What are you putting up with at the moment
- The "shoulds" - What do you think you should be doing
- Frustrations - What things are frustrating about yourself, your life, work etc.
- Desires - What do you really want in your professional or personal life.
What type of coaching are you seeking: life coaching, career coaching, executive coaching, business coaching or any other type of coaching you are interested in:
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Why are you seeking coaching at this time?
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What are the top three things you'd like LESS of in your life?
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What are the top three things you'd like MORE of in your life?
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Are you in a partnership/committed relationship?
___________________________________________________________________________What is your current job/employment situation?
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What would you like to accomplish during your coaching session(s)?
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METHOD OF PAYMENT
_____MONEY ORDER _____CHECK_____MASTERCARD _____VISA
All credit cards will be charged through our business name: CLEAR LIGHT ARTS, ADL.
Credit card number:
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Exp. Date: _______________________ Security Code Numbers: _________
Full name as it appears on the credit card:
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Signature:
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