8/7/26
client
Please allow yourself about 30 minutes to complete your coaching intake questionnaire, and answer each question with an open heart and mind. If you have any questions, please do not hesitate to let me know.
Warmly,
Jia
New Client Intake Questions - Coaching Questions What are your pronouns? {"type":"textarea","name":"__generic","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
Please share what you think would be essential for me, as your coach, to know about your social, cultural, and ethnic identities and locations. {"type":"textarea","name":"__generic2","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
Please describe your current self using five different adjectives. {"type":"textarea","name":"preSessionOutlook","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please tell me just a little about your outlook right now.","height":80,"placeholder":""}
What are some of the pivotal moments that have shaped who you are today? Please share what you believe will be most valuable for me to know about you as your coach. {"type":"textarea","name":"preSessionExcited","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"","height":80,"placeholder":"Share what you believe will be most valuable for me to know about you as your coach. "}
What are the biggest accomplishments in your life? How did you achieve them? Why are you proud of them?
{"type":"textarea","name":"__generic3","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
What is the most challenging obstacle you have had to overcome in life thus far? How did you overcome it? {"type":"textarea","name":"__generic4","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""} What is the vision you have for your life? Another way asking this question, is what do you care most about or w ho are you longing to become?{"type":"textarea","name":"__generic5","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
What is the vision you have for your family and the people you love? {"type":"textarea","name":"__generic6","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
{"type":"textarea","name":"__generic7","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
What values are most important to you and the life you are creating? {"type":"textarea","name":"__generic8","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
What are the top three things you want to focus on in coaching? {"type":"textarea","name":"__generic9","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
Why are these things important to you? {"type":"textarea","name":"__generic10","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
What previous steps have you already taken to achieve your goals? What has been the result so far, and what have you learned? (Basically, what's worked well so far and why) {"type":"textarea","name":"__generic11","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
What is standing in the way of you accomplishing your goals? {"type":"textarea","name":"__generic12","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
What becomes possible when you accomplish these goals? {"type":"textarea","name":"__generic13","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
Where do you see yourself in 6 months? {"type":"textarea","name":"__generic14","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
What do you need from me as your coach regarding support and accountability? {"type":"textarea","name":"__generic15","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
What else should I know about you? {"type":"textarea","name":"__generic16","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
Daily Functioning & Supports Who are the most important people in your life and why? {"type":"textarea","name":"__generic17","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""} Please describe your current support system. Your support system can be a partner, friend, mentor, coach, trainer, co-worker, spiritual guide(s), ancestors, etc., anyone or anything in your best interest. {"type":"textarea","name":"__generic18","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
What, if anything, is missing from your support system? {"type":"textarea","name":"__generic19","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
How would you rate your current happiness or overall life satisfaction level?
1 Least Satisfied <----------> 10 Most Satisfied
12345678910{"type":"select","name":"__generic20","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"1\n2\n3\n4\n5\n6\n7\n8\n9\n10"}
How would you rate your current stress levels on an average day?
1 Low Stress <----------> 10 High Stress
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What is causing you stress? What steps have you taken to deal with your stress? What works best for you with stress management? {"type":"textarea","name":"__generic22","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
What are examples of practices or activities that truly “fill your cup” and give you restorative energy? What “empties your cup” and drains your energy?
{"type":"textarea","name":"__generic23","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
What is your current relationship to health and wellness, i.e., rest, diet, physical activity, therapy, stress, etc.? {"type":"textarea","name":"preSessionStuck","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Really? If so, please just proudly declare that you are ON FIRE. :)","height":80,"placeholder":""}
Anything you consider to be negatively impacting your health and daily functioning? (Alcohol or substance use, time on screens, relationship with food, relationships, loneliness, etc){"type":"textarea","name":"__generic24","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
How aware are of your posture and breath are you on a daily basis?
1 very unaware <----------> 10 Very Mindful (Aware)
12345678910{"type":"select","name":"__generic25","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"1\n2\n3\n4\n5\n6\n7\n8\n9\n10"}
Are you currently seeing any other professionals or providers that might be relevant for me to know about? (therapy, spiritual director, etc ) If so please list name and how long you have been seeing them. {"type":"textarea","name":"__generic26","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
Please check any daily or weekly practices that you engage in, and reflect on your why behind your practice(s)
Mindfulness Meditation Breath work Yoga Walking, Jogging, Running, Biking Strength training Dancing, Shaking Martial arts Writing, Journaling Prayer Humming, Singing Other: {"type":"checkbox","name":"__generic27","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please check at least one item.","options":"Mindfulness\nMeditation\nBreath work\nYoga\nWalking, Jogging, Running, Biking\nStrength training\nDancing, Shaking\nMartial arts\nWriting, Journaling\nPrayer\nHumming, Singing\nOther:"}
Readiness, Capacity, & Commitment
How do you feel about your overall busy-ness?
1 Very busy-ness <----------> 10 Very Mindful (Aware) 12345678910{"type":"select","name":"__generic28","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"1\n2\n3\n4\n5\n6\n7\n8\n9\n10"}
How ready , willing , and able are you to commit to change and consistently practice new skills and ways of being? YesNoUnsure{"type":"select","name":"__generic29","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Yes\nNo\nUnsure"}
Be sure to mark this complete so that I get it before our session. Talk to you soon.