CHPC Client Intake Questionnaire

Name*

First Last

Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Occupation*

Date of Birth*

MM

DD

YYYY

Gender*

Male
Female

Marital Status*

Married
Single
Divorced

Please briefly describe how you heard about my coaching services and why you would like a Strategy Session with me:*

Please rate yourself in the following areas of your life on a scale of 1 (lowest) to 10 (highest):

Clarity: Do you feel you are clear about who you are, your purpose, and the direction you want to go in life?*

Energy: Do you consistently have enough mental and physical energy needed to excel, accomplish your goals, and feel motivated and happy?*

Courage: Do you take action and consistently express who you truly are and what you truly think, need, and desire with the world?*

Productivity: Are you consistently focused and effective, and are you good at minimizing distractions and maintaining priorities?*

Influence: Do you feel you have the social influence with your family, friends, and team needed to accomplish your goals?*

What do you do for a living, and why did you choose that career?*

What are your top 3 goals you are striving to achieve right now?*

What major stressors or challenges are you struggling with right now?*

When you feel like your most successful and happy self, what makes you feel that way?*

What would your dream life look like if you could wave a wand and make it happen?*

What else has prevented you from having that dream life?*

What goal or dream have you ever given up on or failed at, and what do you believe caused you to stop or fail?*

What 3 big changes would you like to make in your life in the next 12 months?*

What are you most proud of and excited about in your life?*

High Performance Questions:

What negative recurring thoughts, fears, or behaviors would you like to overcome in order to feel more psychologically free, confident and successful?*

What eating, exercise or general health habits would you like to begin or break in order to feel stronger and more healthy physiologically?*

If you were more persuasive or influential, what dream or desire would you ask others to support you in achieving?*

When do you struggle to be fully present in your day or in any of your relationships?*

How purposeful do you feel in living each day, and how would you describe your purpose?*

Why would you like to work with a high performance coach?*

Why do you feel you could be a great student or coaching client if we worked together?*

Questionnaire For Your Coaching Strategy Session

Please rate yourself in the following areas of your life on a scale of 1 (lowest) to 10 (highest):

High Performance Questions:

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