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New Patient Questionnaire

 

The purpose of this questionnaire is to provide some information to help create a foundation for the coaching relationship that will best satisfy your needs. There are no right or wrong answers. Your answers will convey what is important and meaningful to you.

Check all that apply
     
     
Name:
Home Phone
Work Phone:
Fax Number:
Email:
Address:
Mailing Address (if different):
Occupation
Age
1. What are your concerns, issues, questions or problems that you want to work on in coaching?
2. What result do you want to get from the coaching?
3. How do you want your coach to be with you?
4. What should the adoption coach know or understand about you and your situation to be most helpful with your concerns?
5. What could you do differently now to help make your problem (issue or concern) improve?
6. What should your coach do and say to help you move forward and achieve your purpose?
7. Describe what a successful and satisfying coaching outcome would look like?
8. Describe the outstanding frustrations and stressors in your life.
9. Describe major sources of satisfaction, support and strength in your life.

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