Client Intake Questionnaire

The intention of this questionnaire is to give you more pointers to assess your current situation and provide me, your coach, with some initial understanding of your current state and your aspirations for the future. This is not a test that will be "graded" -- I will not judge you by your answers, your grammar, etc. Relax and give your best, deepest answers. Feel free to skip any question for any reason.

  1. Describe an endeavor such as a long training, starting a business, a college or graduate school that you have completed.
  2. How successful were you IN YOUR OPINION in that endeavor?
  3. How successful were you IN OPINION OF OTHERS in that endeavor?
  4. Self-assess your spiritual development. Give examples.
  5. Self-assess your emotional maturity. Give examples.
  6. Self-assess your intellectual development. How good are you at critical thinking? Give examples.
  7. Describe a situation that required considerable resources from you (intellectual, emotional, physical, spiritual).
  8. Did you succeed or fail in those circumstances?
  9. Describe a job or event at which you succeeded greatly.
  10. What was your reaction to the success?
  11. How did you handle this success?
  12. What was the outcome of this success?
  13. What have you learned from this success?
  14. Describe a job or event at which you failed badly.
  15. What was your reaction to the failure?
  16. How did you handle this failure?
  17. What was the outcome of this failure?
  18. What have you learned from this failure?
  19. Are you consciously aware of any beliefs that you CONSCIOUSLY hold that don’t serve you or are irrational?
  20. Self-assess your critical thinking abilities.
  21. Do you attend church, temple, etc. regularly?
  22. What is the purpose of your attendance?
  23. Do you participate in a yoga class regularly?
  24. What are you getting out of your participation?
  25. Do you practice a form of meditation or any other contemplative practice? It does not have to be formal.
  26. Have you FORMALLY studied with a spiritual teacher, a guru, a lama, an abbot/abbess (starets), a sheikh, rabbi, or a minister. List all significant engagements if more than one.
  27. What was the purpose, duration and the outcome of the study?
  28. How many languages do you speak fluently? What are they?
  29. Describe a foreign travel or residence experience. Did you like it? How did it change you? Be specific.
  30. When do you get up?
  31. What do you do before breakfast?
  32. What do you usually have for breakfast?
  33. When do you leave for work? 
  34. Where do you work?
  35. How many hours you spend at work?
  36. Do you take work home?
  37. Where to do have your meals?
  38. Who do you typically have your meals with?
  39. Do you like cooking your meals?
  40. Do you have children? How many? What are their ages?
  41. Self-assess your relationship with your children. Be specific.
  42. Generally speaking, do you think your life is working?
  43. Generally speaking, do you feel your life lacks direction, i.e., you feel "lost" right now?
  44. Describe things that feel meaningful to you right now (even if not sure). Give specific examples.
  45. Describe things that feel meaningless right now. Give examples. (e.g., I no longer feel satisfaction from my job. My life feels empty because...)
  46. Is there a question in this survey or a comment to this survey that should be added?
  47. How do you feel right now? Be specific.
  48. How will you know that my coaching has been successful?
  49. What outcome are you looking for from my coaching?
  50. How will you measure these outcomes?