Pre-Coaching Assessment Form

Please complete this form as the first step in helping determine whether Significant Lives coaching is right for you. Many people find that this exercise helps to structure their thoughts and get greater clarity about what they would like to achieve from coaching. Please don’t feel you have to complete all the questions but give attention to the ones that particularly resonate with you.

From the information you provide I will develop a coaching proposal that is specific to your particular needs and will include time frames and cost. This no obligation proposal will be sent to you by email and you can then decide whether to proceed or not.

Contact Details

Your Name*

Your Address

Your Phone*

Your Email*


Date of birth

Marital Status

Spouse or Significant Other's Name

Children's Names and Ages



Our coaching relationship is confidential. Unless you disclose issues, which your coach is required to disclose to the authorities (e.g. intent to harm yourself or others), all of the content of our conversations will be held in confidence.

I accept this confidentiality policy

Previous Coaching/Counselling Experiences

In the past have you worked with:
A Coach How long/What years?
A Therapist How long/What years?

Major Issues Addressed

How was the coaching/counselling helpful?

Worklife Balance

How would you rank your current level of satisfaction with each of the following areas of your life?

Life Area Very Satisfied Satisfied Dissatisfied
Work Very satisfied Satisfied Dissatisfied
Emotional health Very satisfied Satisfied Dissatisfied
Physical health/well-being Very satisfied Satisfied Dissatisfied
Mental health Very satisfied Satisfied Dissatisfied
Finances Very satisfied Satisfied Dissatisfied
Spirituality/religion Very satisfied Satisfied Dissatisfied
Relationship with spouse/significant other Very satisfied Satisfied Dissatisfied
Relationship with children Very satisfied Satisfied Dissatisfied
Relationships with boss or co-workers Very satisfied Satisfied Dissatisfied
Social network/friendships Very satisfied Satisfied Dissatisfied
Self-confidence/self-esteem Very satisfied Satisfied Dissatisfied
Very satisfied Satisfied Dissatisfied


What are you like when you are at your best?

What have you always wanted to do in life?

What accomplishments must, in your opinion, occur during your lifetime so that you will consider your life to have been satisfying and well lived – a life of few or no regrets?

How do you most want to be remembered by those who are closest to you?

If you could devote your life to serving others – and still have the money and lifestyle you need – would you do it? How would it look?

What’s missing in your life? What would make your life more fulfilling?

Do you believe in God or in the concept of a higher power? If so, describe the most useful and empowering aspects of your relationship with God. If not, what reference point do you use?


What are your most important goals for the next 6 or 12 months?

What, if anything, is standing in the way of you achieving your dreams/goals?

What would you like to achieve from coaching?

How would you like your coach to be? (e.g. demanding, gentle, challenging, etc.)

What else would you like your coach to know about you and your current life situation?

Did you find this form:

Thank You

For the time you have taken to answer these questions and for your open and honest responses. You will receive a copy for your own reference sent to the email address provided above.


On taking the first step. Regardless of whether you decide to go ahead with any coaching, just by making contact and writing down your dreams and goals, you have already started to step into your preferred future. That’s significant! Once your completed pre-coaching form has been received, I will get back to you with my recommended approach.