CLIENT INTAKE

CLIENT INFORMATION

YOU MUST HIT THE SUBMIT BUTTON AT THE END

On a scale of 1 to 10 (1 being as bad as it could be and 10 being fully achieved/happy) grade each of the categories below as they are for you today. Example: If you are fully satisfied with the amount of time, energy, attention you are paying towards your savings put a 10 in the box next to savings.

If there is a category that is not applicable, place an NA in the box next to it. For example: you may have no desire to do “Meditation” in which case you write in NA OR you may work alone in which case “Colleagues” is irrelevant, so write in NA.

Remember, this is to measure how you feel NOW and there are no right or wrong answers.

All information is confidential

* Indicates required field

NAME *

FILL OUT THE BELOW ON A SCALE OF 1-10 (10 BEING THE HIGHEST) OR "NA" IF IT DOESN'T APPLY

HEALTH *

FUN/SOCIAL *

FRIENDS *

ORGANIZATION SKILLS *

WEALTH/SAVINGS *

SALARY *

SIGNIFICANT OTHER *

GOAL SETTING *

DIET *

FITNESS *

CAREER/JOB *

FAMILY *

MEDITATION/RELAXATION *

COLLEAGUES *

GIVING BACK/CHARITY *

SPIRITUALITY *

i can't do that because...

One of the many factors we will be talking about is why you are stuck and what is keeping you in a holding pattern when trying to moving forward.

Some people call them REASONS, I like to call them out for what they are, EXCUSES. We all have them (count me in!) and we all hold them up to ourselves and others when something gets hard to do or is too hard to think about doing.

I always imagine jars of excuses on a shelf, that you can pull down to look at and then show yourself and the world why you can't accomplish something. STOP IT. It doesn't make anything in your life better.
Remember...LIFE IS 10% OF WHAT HAPPENS TO YOU AND 90% OF HOW YOU REACT TO IT.

That said BE HONEST and list the three excuses that you use which are holding you back in work and/or life.

EXCUSE #1 *

EXCUSE #2 *

EXCUSE #3 *

ARE YOU ON A ROLL?!? DO YOU HAVE ANY ADDITIONAL EXCUSES THAT YOU WANT TO NOTE? IF SO, HERE IS YOUR CHANCE. *

expectations

It is REALLY important that we are all on the same page as it relates to your goals and how to achieve them, who is responsible for achieving them and how long it will take to achieve them. That said, STEP ONE is filling out the below.

What is your minimum requirement/outcome from advising/coaching that will make you think it was a worthwhile investment of time and resources? *

What is your dream outcome. What is the thing or things that if you achieved would have you thinking hiring an advisor/coach was one of the best decisions you ever made? *

Please tell me things you think are likely to motivate and/or de-motivate you.

MOTIVATE: *

DE-MOTIVATE: *

In an ideal world, what would you really like to achieve in your life that you have maybe given up on or think is out of reach? Please take your time in answering and provide as much detail as possible. *

DON'T FORGET TO HIT THE SUBMIT BUTTON BELOW! THANK YOU.

~Annie

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