Jean Williams, LCSW - Believing In Self

Intake Form

BELIEVING IN SELF
Client Questionnaire for TeleCoaching

As your coach, it is important for me to understand who you are, what you value, and how you approach life. This Questionnaire is designed to promote exploration about what you really want out of life. Please set aside some time to thoroughly consider these questions, and return to me by email.

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Name

First

Last

Phone Number

Your Birthdate

MM/DD/YYYY

Address

Full Address, City, State and Zip.

Please Answer the following questions as clearly as possible:

1- Why have you hired me?

2. What are the primary short-term goals that you want to focus on in the next eight sessions?

Goal 1

Goal 2

Goal 3

Goal 4

Goal 5

3. What would you like to do to or accomplish during your lifetime (personally or professionally), in order to consider your life well lived, with few or no regret?

3. What would you like to do to or accomplish during your lifetime?

4. What is your passion in life or what makes you happiest and most fulfilled?

4. What is your passion in life?

5. What are your favorite pastimes (name at least five)?

5. What are your favorite pastimes?

6. What motivates you or gives you energy i.e. Deadlines, caffeine, your values, meditation, exercise, nature, status, adrenaline, etc.)?

6. What motivates you or gives you energy?

7. What do you consider to be your personal and/or professional strengths?

8. Tell me five aspects of your personal/professional life, past or present, of which you are most proud?

9. Are you aware of any behaviors/beliefs that stand in the way achieving professional success and having a life you really love?

10. Tell me what I should know about you to coach you best?

11. How will you know that our coaching is working?

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