Intake Form - Performance Coaching

We're about to begin a very important process dedicated to you and your goals. 

The purpose of these questions is to help me align with where you're at, where you've come from, and where you're headed - so that I can support you on your performance coaching journey in the best way possible.

Please give some thought to the questions below and share your ideas. Click SAVE & SEND when you're done.

Thank you.


The information on this form shall remain confidential.

First, the easy questions. 
What part of the world do you live in?

What is your occupation?

When is your birthday?

Performance Coaching is about making some kind of shift in your life. What shift are you aiming for?

I am pleased and/or satisfied with the following aspects of my life (check all that apply):

To me, success means...

When it comes to my life and my accomplishments, I am most proud of...

Of all my good qualities, the quality in myself that I like the most is...

I am exactly the person I want to be right now.

I am at my best when I am...

My main priorities in life right now are...

What things in your life hold your attention and consume your energy?

Name an obstacle or hindrance that you wrestle with - that the people around you are aware of. 

Now, name an obstacle or hindrance you face that the people around you have no idea that you wrestle with. 

Ponder this: Sometimes, it seems like I cannot expand to my full potential because of...

Things are not okay in my world unless I am...

If there is anything that knocks me off my center or causes me to loose my objectivity, it's ________________________________________.

In the privacy of my own mind, I worry about ________________________________.

I suspect I might have a blindspot pertaining to _________________________________________.

If other people knew about ____________________________________, they would probably think less of me.

The way I grew up really taught me...

If there is anything you would like me to know about you that hasn't been mentioned so far, please feel free to share...

Cell Phone Number: