Coaching Intake Questionnaire Coaching Intake Information NameThis field is for validation purposes and should be left unchanged.Name(Required) First Last Address(Required) Street Address Address Line 2 City State / Province / Region Post Code/Zip Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country What’s your tech-frence for communication between our sessions?(Required)Please selectEmailSMSWhat's AppVoxerOtherBetween our coaching calls, we can do check-ins on Thursdays during business hours. You can ask for any feedback, insights or advice, between our coaching sessions and can share screen shots of your data. What are your ‘tech-spectations’ (i.e. how do you prefer to digitally communicate- video, audio, email, SMS)?(Required)What’s your job title?(Required)What are some of the core tasks you perform in your role?(Required)List 1-3 goal/s you’d like to achieve by us working together.(Required)Have you previously taken any steps towards achieving these goal/s? What worked and what stopped you achieving these goals?(Required)What would success look like for you at the end of our time together?(Required)On a scale of 1 to 10, how would you rate your desire to achieve these goal/s (with 1 being very low motivation and 10 is extreme motivation)?(Required)12345678910On a scale of 1 to 10, how would you currently rate your physical health (with 1 being very poor physical health and 10 being excellent health)?(Required)12345678910On a scale of 1 to 10, how would you currently rate your stress tolerance (with 1 being very poor stress tolerance and 10 being excellent stress tolerance)?(Required)12345678910On a scale of 1 to 10, how would you currently rate your productivity (with 1 being very poor productivity and 10 being excellent productivity)?(Required)12345678910On a scale of 1 to 10, how would you currently rate your levels of exhaustion (with 1 being very exhausted and 10 being energetic)?(Required)12345678910On a scale of 1 to 10, how would you currently rate your focus (with 1 being very poor focus and 10 being excellent focus)?(Required)12345678910Do you know which of the three pillars of powered-up performance that you’d like to focus on first in our coaching (don’t fret, we’ll flesh this out in our first session if you’re unsure)?(Required)Please selectStress ToleranceFocusRecoveryIs there anything else I should know about you before we begin? (i.e. any important health or personal information I should know about you before we work together)? Please rest assured your privacy and confidentiality is assured throughout our entire coaching process.(Required)
