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I mainly consider myself as religious, pragmatic/evidence based, spiritual/belief-based, belief-based but not spiritual, or other. Please explain.

What are the biggest changes you want to make in your life/relationship in the next 3 months?

What are the biggest changes you want to make in your life over the next 3 years?

What do you most want to achieve for yourself in your life/career/relationship?

What are the restraining forces keeping you from achieving these?

What do you expect to achieve as a result of hiring me?

What is the hardest thing in your life that you have had to overcome?

What major transitions or life changes have you had in the past two years? (Example: Entering or approaching a different age, a new or different relationship, job role, residence, a change in children’s ages/stages, etc.)

Who are or have been your major role models? Why?

Have you worked with a counselor/coach before or a similar one-on-one adult relationship? If so, what worked well for you and what did not work in the relationship(s)?

History: What would you like to share with me?

Please list any psychiatric or “mental health” problems you have been diagnosed with:

Please list any medical or “physical” problems that you have been diagnosed with:

Please list any medications you currently take, and what they are taken for:

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