Copyright 2011      Kellie Nicholson
Life Coaching Intake Application
Personal Growth Center
for Excellence in Life
Name:
Email Address:
What are you looking for?
Career
What do you do?
Are you happy with your career?  
 Yes
 No
Do you feel valued?
 Yes
 No
Is there opportunity for advancement?
 Yes
 No
Money
Do you have a savings plan?
 Yes
 No
Are you able to retire?
 Yes
 No
Are you happy with your income?
 Yes
 No
What is your current income annually?
What would you like your annual
income to be?
Relationships
Do you have a partner in life?
 Yes
 No
Are you satisfied with your relationship?
 Yes
 No
Would you say your partner is happy with you?
 Yes
 No
Do you have solid friendships?
 Yes
 No
Health
Are you healthy?
 Yes
 No
Do you get annual physicals?
 Yes
 No
Do you eat well and exercise at least three
times a week?
 Yes
 No
Life
Do you have plans and goals?
 Yes
 No
Do you have any sources of inspiration?
 Yes
 No
Do you belong to any organizations?
 Yes
 No
Which ones?
How old are?
What's the highest level of formal
education you have completed?
What other types of training have you
had?
Clarity is very important in helping you move forward to improve your life.  
Though one area of your life may be what you want to concentrate on, it
may be a different area that is stifling your progress.  Please answer these
questions from your heart and keep in mind there are no right or wrong
answers.