First Name *

Last Name *

Email *

Phone *

I understand my emotional triggers and can recognize them when they show up. *

1 = Strongly Disagree

2 = Disagree

3 = Neutral

4 = Agree

5 = Strongly Agree

I am aware of the beliefs and patterns that influence my decisions. *

1 = Strongly Disagree

2 = Disagree

3 = Neutral

4 = Agree

5 = Strongly Agree

I can shift out of negative thinking and reframe challenges with a growth mindset. *

1 = Strongly Disagree

2 = Disagree

3 = Neutral

4 = Agree

5 = Strongly Agree

I regularly self-reflect and take responsibility for my thoughts, actions, and outcomes. *

1 = Strongly Disagree

2 = Disagree

3 = Neutral

4 = Agree

5 = Strongly Agree

I have a clear vision for what I want my life to look like over the next 1–3 years. *

1 = Strongly Disagree

2 = Disagree

3 = Neutral

4 = Agree

5 = Strongly Agree

My goals are aligned with my personal values and what truly matters to me. *

1 = Strongly Disagree

2 = Disagree

3 = Neutral

4 = Agree

5 = Strongly Agree

I know my priorities and rarely feel unsure about what I should focus on. *

1 = Strongly Disagree

2 = Disagree

3 = Neutral

4 = Agree

5 = Strongly Agree

I feel motivated and energized when I think about my future direction. *

1 = Strongly Disagree

2 = Disagree

3 = Neutral

4 = Agree

5 = Strongly Agree

I manage stress well and rarely feel overwhelmed by responsibilities. *

1 = Strongly Disagree

2 = Disagree

3 = Neutral

4 = Agree

5 = Strongly Agree

I have strategies in place (breathing, mindfulness, downtime, etc.) that help me stay centered. *

1 = Strongly Disagree

2 = Disagree

3 = Neutral

4 = Agree

5 = Strongly Agree

I recover quickly from emotionally challenging situations. *

1 = Strongly Disagree

2 = Disagree

3 = Neutral

4 = Agree

5 = Strongly Agree

I maintain a healthy balance between work, personal life, and rest. *

1 = Strongly Disagree

2 = Disagree

3 = Neutral

4 = Agree

5 = Strongly Agree

I follow consistent routines that support my physical, mental, and emotional well-being. *

1 = Strongly Disagree

2 = Disagree

3 = Neutral

4 = Agree

5 = Strongly Agree

I am disciplined with habits that move me closer to my goals. *

1 = Strongly Disagree

2 = Disagree

3 = Neutral

4 = Agree

5 = Strongly Agree

I manage my time effectively and avoid frequent distractions. *

1 = Strongly Disagree

2 = Disagree

3 = Neutral

4 = Agree

5 = Strongly Agree

I regularly feel productive and accomplished at the end of the day. *

1 = Strongly Disagree

2 = Disagree

3 = Neutral

4 = Agree

5 = Strongly Agree

I follow through on the commitments I make to myself. *

1 = Strongly Disagree

2 = Disagree

3 = Neutral

4 = Agree

5 = Strongly Agree

I take action even when I feel uncertain, uncomfortable, or unmotivated. *

1 = Strongly Disagree

2 = Disagree

3 = Neutral

4 = Agree

5 = Strongly Agree

I track my progress toward my goals and make adjustments as needed. *

1 = Strongly Disagree

2 = Disagree

3 = Neutral

4 = Agree

5 = Strongly Agree

I have strong accountability systems (self or external) that help me stay on track. *

1 = Strongly Disagree

2 = Disagree

3 = Neutral

4 = Agree

5 = Strongly Agree

What specific goals or changes are you hoping to achieve, and why are they important to you right now?

What challenges or obstacles have kept you from reaching these goals on your own?

How open are you to making changes with the support of a coach to improve your outcomes?

Very Likely

Likely

Unsure

Unlikely

Very Unlikely

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