Personal Information Questionnaire

BUSINESS MISSION
What do you want, professionally, for your clients, patients,employees and others?
Why do you do what you do? What do you do that is unique and/or excites you?

LEGACY
What do you want to leave others after you are gone? Be specific.

PROBLEMS, CONCERNS, & BLOCKS
WHAT IS IN YOUR WAY?

PERSONAL PROBLEMS OR BLOCKS
What are the three biggest personal challenges confronting you at this time?

BUSINESS PROBLEMS OR BLOCKS
What are the three biggest business challenges confronting you at this time?

PERSONAL OR BUSINESS CONCERNS
What do you want to get better at doing?

LIGHTNING ROD ATTRACTIONS
What kind of problems and crises do you keep attracting?

RECURRING BEHAVIOR PATTERNS, BAD HABITS & BLOCKS TO SUCCESS
What do you keep doing that limits your success?

SUPPORTIVE STRUCTURES DURING COACHING
WHAT STRUCTURE WOULD MAKE YOUR LIFE EASIER AND WILL
MAKE THE COACHING MORE EFFECTIVE?

10 DAILY HABITS
Clients who take good care of themselves are able to achieve more with less cost.
Make a list of the 10 daily habits that will keep you well.
Use a Daily Habits Tracking sheet if desired. Focus on health and emotional habits.

HIGH PERSONAL STANDARDS
What high standards are you now willing to hold yourself to, consistently?

CLIENT COACHABILITY INDEX
HOW COACHABLE ARE YOU?

Instructions: Enter the number which comes closest to representing how true the statement is for you right now. 1 being the least true and 5 being the most true. Then, score yourself, using the key just below the questions. Your coach needs for you to be at the place in your life where you are coachable. This test helps him/her - and you - discover how coachable you are, right now.

I can be relied upon to be on time for all calls and appointments.
This is the right time for me to accept coaching.
I am fully willing to do the work and let the coach do the coaching.
I keep my word without struggling and sabotaging.
I'll give the coach the benefit of the doubt and "try on" new concepts or different ways of doing things.
I will speak straight (tell what's really true) to the coach.
If I feel that I am not getting what I need or expect from the coach, I will share this as soon as I sense it and ask that I get what I want and need from the relationship.
I am willing to eliminate or modify the self-defeating behaviors which limit my success.
I have adequate funds to pay for coaching and will not regret or suffer about the fee. I see coaching as a worthwhile investment in my life.
I am someone who can share the credit for my success with the coach.

SCORING KEY
10-20 Not coachable right now.
21-30 Coachable, but make sure the ground rules are honored!
31-40 Coachable
41-50 Very coachable: ask the coach to ask alot from you!

CLIENT DATA
THE BASICS

( * indicates required fields )
Name:
*
Company:

Nature of business/Position:

Occupation:

Street Address:
*
City:
*
State:
*
Zip:
*
E-Mail Address:
*
Phone:
*