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PLEASE MAIL, e-MAIL OR FAX THIS FORM TO CLEAR LIGHT ARTS, ADL
Ken Page/Rev. Dr. Nancy Nester
Post Office Box 1500, Cleveland, Ga 30528

Tel: 706-865-0322 (ofc) ---- 706-223-0291 (fax)
CONTACT US

 

Coaching: Initial Questionnaire

 

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?

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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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