Fill out my Confidential registration form and preparation questionnaire!

These forms will help me get to know you better before we start so that we can maximize our time together.

Personal Information

As a Licensed Clinical Social Worker, I am bound by state licensing regulations to uphold your confidentiality and practice in an ethical manner. This includes informing you if I think you would benefit more with a different service. In addition, any request for disclosure of your personal information requires your permission and informed consent. Since I am working on an International Coaching Federation license, I do ask if I can release your name and telephone # to verify the required coaching hours. NO other information is allowed on the form which is only viewed by a few people.

Our signitures below attest to our mutual willingness to enter into this coaching relationship as defined by the terms listed above. I look forward to working with you and taking this journey together! I hereby attest to my mutual willingness to enter into this coaching relationship as defined by the terms listed above. First and Last Name (required):

Preparation Questionnaire

a clearly articulated goal is a good place to start the change process. If you are not sure how to summarize your goal, the attached questionnaire may clarify your desires. Please complete the following questionnaire prior to our first coaching session. These questions deserve your careful consideration. It is my hope that they will help you organize your thoughts and clarify your goals. This is the beginning of an important change process for you, so I will give your answers thoughtful attention prior to our first meeting.

Wheel of Life – How balanced are the components of your life? List a number for each section of the wheel in the box below, starting with the number for Business/Career and rotating around the wheel clockwise until you reach Physical Environment. The outer edge of the wheel at 10 indicates full satisfaction and closer to the center indicates less satisfaction. Don’t expect a complete wheel!

1. Please describe the issue, the question, the need or goal that is prompting you to seek services. Why have you chosen me to work with you?

2. What are you hoping to accomplish? What is the desired outcome?

3. What are your strengths, gifts and passions that you bring to life? Are you able to fully express them at this time?

4. What are the greatest challenges in front of you? What are your concerns about them?

5. What is your definition of success? How have you been successful in your life?

6. Is there something that you hope to achieve in your lifetime? How important is it at this time?

7. Do you have a 5 year or long term goal – is it part of this goal?

8. What brings you joy, pleasure and support that balances your life and that you can count on as you go through this change process?

9. What do you feel is missing in your life that you would like to bring in to achieve greater balance?

10. What is your spiritual foundation as in any form of belief or faith in God, Spirit, Source Energy, or faith practice? I will honor whatever is important and works for you.

11. Do you have a spiritual practice, be that prayer, meditation, reading, writing, walking, or any quiet time alone for reflection that helps support you? How long have you been practicing it?

12. What does leadership mean to you? How have you been a leader in your life? Are there changes in this you want to make?

13. Do you believe you are a co-creator with responsibility for making things happened the way you want? What experience do you have with this concept?

14. Is there something else that is important for me to know as we begin our work together?

Thank you for your thoughtful response. I look forward to reviewing it with you.

Click this button to return to the main registration page.