Introductory Questionnaire

The following items constitute the information that will assist me in understanding you and your needs, so please send me your thoughtful responses to the two questionnaires and the following ten questions by email or fax. If you have an Internet account or access through an on-line service, I can also send you the documentation in electronic form.

Take as much space as you need, using attached pages where necessary. Send the signed contract back to me with your responses to the various questionnaires or separately if you wish to have more time.

(1) Your Profile

Zip Code
180 Day commitment starting on (date):
Initiation fee:
(2+ hours)) @ $ one-time
Coaching ($ /mo.) @ $ per month
Intensive Coaching ($ /mo.) @ $ per month
Coaching/Advisory Board Role ($ /mo.) @ $ per month
Half-Day/Full-Day Workshops (varies) @$

Call days and time set at a mutually convenient time. However, if necessary, with at least 24 hours notice they may be changed. Please honor the appointment and call me at the agreed time at (203) 975-0320. Your time is precious, so please treat your investment and your coach’s time, with respect. Please confirm your commitment to this partnership when completing this section.

I commit to this partnership for a minimum period of 180 days and to:
  • Make this experience a success for me.
  • Do anything necessary to succeed in this endeavor.
  • Be truthful and honest in our relationship
  • Respect the agreed appointment schedule.
  • Pay the initiation fee when submitting the completed documentation, and the monthly fee in advance by the first day of each month.
Agreed by (sign or, if e-mailed, write your name here):

(2) Your Background.

Tell me something about your personal background. Where you are from, where you grew up, something about your family and any other details that you think will help me better understand and better support you.

3) Send me a personal statement about yourself that includes:

The top 5 accomplishments, thus far, in your life.

What you really want to make sure you do/accomplish before you die.

What you really want from life — more than anything else.

What do you want to become?

(4) Your top one or two LONG term goals:

Choose a list of at least two goals you wish to start working on during our time together. Make sure these include both personally and professionally-oriented goals. Things you REALLY want, not what you SHOULD do. If you really want to create your path to realize these goals, list 5 ACTION steps necessary to achieve EACH goal.

(5) The burning one or two SHORT term goals you want to achieve over the next 90-120 days.

(6) The changes/actions you believe are needed for these goals to be accomplished easily?

(7) What habits/activities/thought processes you believe need to be dropped, simplified or let go of, in order to truly move forward, quickly?

(8) Is there anything else I should know that will help me help you?

(9) Why are you working with me? What do you need? Or, is there something else you want to know about me or my work?

(10) How coachable are you?