Coaching Intake Form

Your Name*

First Last

Your Email*

Enter Email Confirm Email

Skype Handle (Required for our Face to Face Video Call)*

Mobile Number (just in case Skype Gets Disconnected)*

Please enter Country Code (if not USA), then Area Code, then your Number:

Country (State if within the US)*

I need this to understand what Time Zone You're in.

Information About You

Please complete this section as in depth as possible to ensure wen can make the best use of our time, from the first minute we connect. :)

What is the most important issue in your life where you would like to experience a SIGNIFICANT breakthrough?*

Why would you like to make a shift or change in this area today. In other words why are you sick and tired of not conquering this?*

What are the top 5 negative emotions you experience on an average day/week?*

What are the top 5 positive emotions you experience on an average day/week?*

On A Scale from 1-10 How would you rate your degree of happiness today?*

What are the top 2 emotions you'll do anything to experience & why?*

What are the top 2 emotions you'll do anything to avoid feeling & why?*

What do you habitually do to when you're feeling stressed, fearful, or sad? (please be super honest) *

Only list the negative and positive ways you most consistently use.

If you had the power to change anything in your life (regardless of how difficult) what would it be?*

What would you say are your greatest virtues?*

What are your least empowering habits?

What is your idea about change, meaning how difficult or easy is it to change something important in your life?*

Are you currently taking any prescription drugs (ie anti-depressants, sleeping aids, etc)?*

What is the biggest lie you've consistently told yourself?*

Please add anything else you feel will give me a better understanding of where you are today vs where you want to be.