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First Name

Last Name   

City

State

Zip  

Home Phone

Cell or work phone

E-Mail

How FULFILLED and satisfied are you in each of the following domains of your life?

(Rank 1-10.  Be honest—10 is totally 100% satisfied;  1 is awful; totally dissatisfied)

     Work / Career

1 2 3 4 5 6 7 8 9 10

Family Relationships

 Quality Personal Time

     Spirituality

Health / Fitness

  Friendships

Home Environment

Fun and Relaxation

Financial  Wellbeing

Self-fulfillment;

general happiness

Check any statements that are true for you.

There are things in my life I purposely avoid 

There are things that I say I want to do, but never get around to doing them.  
There are many things that I just can't seem to find time or money for 
There are a lot of things I would like to do, but don't seem to have the skills for
I avoid doing certain things out of fear of failure
I avoid doing certain things because I might offend someone
I make a lot of excuses for not doing what I think I should

 I am uncertain about what I want for my future

There are certain things that I lie about pretty consistently

I tolerate a lot of things, even though it makes me unhappy

What other people think of me is very important to me

How committed are you to making changes to improve your life / health / well-being?

(10 being totally 100% committed; 1 being not committed (just thinking about options)

1 2 3 4 5 6 7 8 9 Let's Get Moving! (10)

Yes No     Are you in good mental health?

Yes No     Have you ever been suicidal?

Yes No     Are you currently under the care of a mental health professional?

Yes No     Have you been prescribed psychotropic medications in the past?

Statement of Understanding

I understand that Life in Motion Coaching is a service that provides personal coaching and weight loss coaching to individuals and groups.  Coaching is not a substitute for counseling or therapy. The coach is not acting in the capacity of a licensed therapist. The coach's role is to support, encourage, motivate, advise, provide information and guidance. The client's role is to weigh the information and advice provided before taking any steps. The client understands and acknowledges that the coach holds no responsibility for the clients' actions. The client takes full responsibility in the decisions they make after being coached as well as for the consequences of those decisions.

  I agree                                       I disagree