Reflections Questionnaire



Please complete the following questionnaire, which helps me to understand more about you and your goals. This will enable us to hit the ground running in our sessions together. Please be as open and honest as possible. Print the form before sending if you would like a copy for your records.

Name:
 

Email:
 

Date:
 

Your Goals:
What are the three biggest changes you want to make in your life in the next 6 months?

 






What are the three biggest changes you want to make in your life over the next 12 months?

 






What do you feel is stopping you from reaching your goals?

 

Your History:
What are your 3 greatest accomplishments over the last 3 years?

 






What is the hardest thing in your life that you have had to overcome?



Who are or have been your major role models and why?



Have you worked with a coach before or a similar one-on-one adult relationship (e.g. tennis coach, piano teacher, and therapist)? If yes, what worked well for you and what did not work in the relationship(s)?



What would you like to improve in your current situation and why?



What do you like most about what you do?



What do you like least about what you do?



Personal Shift:
Coaching helps you shift your perspective and "where you come from in life" to one that really empowers you and lets you accomplish with ease. What kind of shift do you want now? List shifts you would like to make in the following areas of your life.

Family/home life:
 
Financial situation:
 
Career or Business life:
 
Personal Character:
 
Relationships:
 
Leisure time:
 
Self-care:
 
Learning:
 
Other:
 
Your Life:
What is your favorite part of your typical day?



What is your least favorite part of your typical day?



Looking at the past six months of your life, do you like the direction your life is moving in and why?



On a scale of 1 to 10, 10 high, rate the amount of stress in your life right now. What are your primary stressors?



What do you feel contributes the most to your stress?



List five things that you are tolerating or putting up with in your life. (examples: information you can't find, clutter, rude friends, poor lighting, tight shoes, dented car, job dissatisfaction, dead plants, broken equipments, old appliances, etc.).













What motivates you?



Coaching:
What would you like me to do if you get behind on your goals?



What types of approaches discourage you or take away motivation?



How will you know when you are receiving value (i.e. your money's worth) from the coaching process?



What else do you want your coach to know?











Cheryl Vallejos




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