Coaching Application

First Name: (required)
Last Name: (required)
Email Address: (required)
Office Phone: (required)
Cell Phone: (required)
Complete Mailing Address

Please answer these questions in GREAT detail and specificity so I can best serve you and customize every detail of coaching to YOU!!
Years in Practice:
Current Monthly Income
Current Monthly Expenses
Number of Staff

Marital Status
Children

Where are you now?

Where do you most want to go?

What is your primary obstacle?

What have you tried thus far to make a change that hasn’t worked?

What causes you the most stress about the way that you’re currently living?

Do you feel there’s more to living than how you’re currently living? If yes, what’s missing?
Please rate yourself in the following systems:

    • 1=Not happening at all
    • 2= Occurs on occasion
    • 3=Done at least monthly
    • 4=Completed daily but not fully leveraged
    • 5=Completed daily and with several facets of leverage

      Referral Request

      Sharing Testimonials

      Weekly Health Talk

      Empowering Table Talk/Daily Education

      Daily Success Check Sheet
What is your primary objective for a coaching relationship? In other words, what do you want to achieve MOST?
What is your primary goal for our first 30 days together? 60 days? 90 days?
What should I know about you to be the best coach possible for you?
What will most “fire” you up?
What will extinguish your hope and drive?
What are your expectations of me as your coach?
What are your expectations of YOU in this relationship?
Where do you MOST want to begin coaching?
What must occur within our first 90 days of coaching for you to be completely satisfied and to want to continue on together?

Which defines you best:

  • A. Help clarify my objectives, help me with the plan, and then wait for me to check in. If I can’t figure something out, I’ll let you know.
  • B. Help clarify my objectives, help me with the plan, and then give me weekly assignments. I’ll check in as necessary.
  • C. Help clarify my objectives, help me with the plan, and then give me weekly assignments that I’ll check in with you on every week.
What is the purpose of your business?
Do you feel you’re fully living your maximum potential?
How much money do you have to make each month?
How much money do you want to make each month? And why?
After sending me this application you will be directed back my front page. Congrats!
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