Pre-Clarity Session Questionnaire

Date

Month Day Year Hour Minutes AM/PM Option

Name *

First Name Last Name

Phone Number *

Area Code Phone Number

E-mail *

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Would you like to receive a "free gift "5 Keys to Rising Up into your Empathic Leadership" ?

Yes No

Thanks so much for your interest in 1:1 Coaching. In order to make sure that I can serve you, and you get the most out of our time together, please answer the following questions:

1. Have you ever been coached/had a coach before? If so what was your experience? what worked and what didn't work?

2. What would you like to change in your business and life through coaching? In other words, what is your motivation to hire a coach?

3. How committed are you to taking action steps to change your situation and/or reach your goal? 1-not committed and 10-completely committed and ready

4. What are your expectations from me as a coach, what woud you like to gain from our sessions together should you choose to move forward with coaching?

5. Do you consider yourself Spiritual? If so, please describe your spiritual beliefs.

6. What else have you tried in the last few months and years to improve your situation?

7. When you are faced with challenges and/or problems, how do you usually solve them? briefly describe the process you use.

8. What do you see as your main source or sources of stress?

9. Are you willing to invest time and money for support with your transformation?

10. Have you been diagnosed with any Mental Illness? If so what is the diagnosis? What if any medications are you taking?

11. What if anything would get in the way of you moving forward with receiving support?

Are you serious about hiring me or a coach?

Yes No Not Sure

How/Where did you find me?

Please indicate 3 times/days you are available in the next two weeks:

***Know that whatever you share with me is confidential. I do not share the information with anyone unless I seek support from my mentor.

I will review your form and get back to you withing 48 hours to book a session if it seems like a good fit.