Request Coaching Intake

Performance Powered By Wellness™

Welcome to Your Request For Coaching Intake.

This questionnaire is designed to help us better understand your current challenges, goals, and areas of focus so we can tailor a personalized coaching experience with clarity and intention. It may be used for self-initiated one-on-one coaching or employer-sponsored coaching for an individual leader or team member. It also helps us determine whether coaching is the right fit for your needs and goals at this time.

Your responses are confidential and will be used only to prepare for your coaching engagement and guide the development of a focused, individualized approach. There are no right or wrong answers. The goal is to clarify priorities, identify opportunities for growth, and ensure we begin with a clear understanding of your needs.

Thank you for sharing your perspective. We look forward to exploring the possibility of partnering with you to strengthen resilience, remove barriers, and support sustainable performance and well-being.

Section 1: Your Contact Information

Your First & Last Name

So we know who we’re partnering with.

Best Email to Reach You

Used only for coaching communication and next steps.

Best Contact Phone Number

Your Role or Current Focus (e.g., leader, professional, entrepreneur, caregiver, transitioning roles)

This helps us understand your current context.

What prompted you to seek one-on-one coaching at this time?

You don’t need to have it all figured out — a few words is enough.

What would meaningful progress look like for you over the next few months?

Think in terms of how you want to feel, function, or show up — not perfection.

Section 2: Quick Focus Snapshot. Which area(s) feels most important to focus on right now?

If you’re not sure yet, that’s okay—choose what feels closest.

Energy, focus, or mental clarity

Stress, overwhelm, or burnout

Work–life balance or boundaries

Confidence, motivation, or direction

Health habits or consistency

Leadership or communication challenges

I’m not sure yet — I want help clarifying

(OPTIONAL) Which is the highest-impact area(s) for development in your life right now? If you’re not sure yet, that’s okay—choose what feels closest.

Stagnant/Held Back

"Fearless Alignment". You're ready to uncover what truly drives you and pinpoint the fears and misunderstandings holding you back. Through personal reflection and value realignment, you're ready for a transformative journey that will help you reconnect with your core motivations and desires. You know it is time to stop feeling stuck, embrace self-development, and focus on achieving your true potential.

Stress/Overwhelm

“Mastering Mindfulness” . Your life is overwhelmingly busy, making it a struggle to stay ahead. This interferes with your ability to perform and leaves you stressed. You’re ready to identify the root causes of distress and get unstuck.

Mental Fatigue/Burnout

“Exhausted to Energized” . You’ve been overwhelmed and stressed for so long that it’s taking a toll on your mental faculties and physical stamina. You’re ready to boost your performance and enhance your wellness.

Disengaged/Unhealthy Habits

“Transform Self-limiting Beliefs & Self-Sabotage” You’ve felt challenged and stagnant in your performance, with depleted energy leaving you constantly drained. Your habits are negatively impacting your personal and professional life. You’re ready to realign, restore, and rebalance for self-discovery, relief, and a positive outlook. You want to boost your confidence, regain your energy, and become the best version of yourself.

Other

You may not know exactly what you need—but you know you need support. If you’re feeling overworked, frustrated, or struggling to maintain balance, this is for you. Together, we’ll assess your current situation, identify stress and pain points, and create clear paths toward your success. You’re ready to take the first step, gain clarity, and start making meaningful changes.

If you chose “Other” or want to add context (optional):

A few words is enough.

Section 3: Questions to Help Illuminate the Path

1. Did your employer recommend coaching? (Optional)

No Yes

If yes, share only what you’re comfortable sharing.

2. Do you currently have a primary medical provider for routine wellness care? (Optional) This helps us understand your overall support network.

Yes No Prefer not to answer

Optional Follow-up: Last routine wellness checkup timeframe (approximate)

4. What are your top priorities you want to achieve? (Optional)

Think outcomes—how you want to feel, function, or show up.

5. Why is making a change important to you right now? (Optional)

Short answer is fine.

6. What’s been getting in the way? (Optional)

Barriers can be internal (mindset) or external (time, workload).

7. What kind of support helps you follow through? (Optional)

Examples: accountability, structure, check-ins, encouragement.

8. Realistically, how much time can you dedicate to coaching actions? (Optional) Choose what’s sustainable—not perfect.

Weekly

Bi-weekly

Monthly

Varies/not sure yet

9. Where are you in the process of investing in your performance and wellness? (Optional) Helps us match you to the right next step.

Exploring options

Ready to start soon

Ready to start now

10. What’s your prior experience with coaching? (Optional) If none, that’s completely fine.

None yet

Some experience

Extensive experience

11. What results have you seen from past programs (if any)? (Optional)

Wins and disappointments both help us tailor better.

12. Anything else you’d like us to know? (Optional)

Optional—share only if helpful.

Section 4: Coaching Program Options

13. Which coaching options are you interested in? (Optional | Check all that apply)

1-Hour Laser Focus

One-Day Strategy Focus

One-Week Intensive Program

One-Month Program

Three- Month Program

Six-Month Program

Section 5: Investment

14. Investment range (optional—helps us tailor recommendations) Optional. If you’re unsure, you can skip this.

$2,399 - $5,999 $6,000 - $10,999 $11,000 - $50,999 $51,000 - $150,999 $151,000 and over

How did you hear about our services?

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