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Name (legal and what you are called)

Address

Date of Birth

Marital Status

Phone Number

Occupation

What hobbies and activities bring you joy and how often do you engage on those?

What are your three top qualities? Feel free to celebrate yourself and brag a bit!

What are the three things about yourself that you most need/want to work on or wish you can change?

Do you have a trusted mentor or guide that you reach out to for advice or guidance when needed? If so, please tell us more about this person and your relationship to them. If you do not have such a person, what is preventing you from having someone like this in your life?

What are the 3 goals you want to achieve over the next three months? What are the three biggest changes?

What would you say have been your three greatest accomplishments in your life to date? What is the hardest thing you have ever had to overcome?

Who are or have been your major role models? Would you be willing to add some? Why?

What major transitions have you had in the past two years? (i.e. – entering or approaching a new decade of life, a new relationship, a new job, a new role, a new residence, changes in children’s ages/stages of life, separation, divorce, death of a loved one, birth of a child, marriage, etc.)

Who are the key people in your life and what do they provide for you?

What are your primary stressors? List five (5) things that you are tolerating or putting up with in your life at present. (i.e. – information you cannot find, rude people, poor lighting, tight shoes, dented car, job dissatisfaction, dead plants, broken equipment, old appliances, etc.)

What is the hardest thing you have ever had to overcome?

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