New Client Questionnaire

Jeffery J Horacek, O.D., C.N.C.

JeffHoracek.com

New Client Questionnaire

Name

Date

Please answer the following in as much detail as needed. Then return to the coach 24 hours prior to your first session.

1. How did you hear about my coaching services?

2. Have you had any prior coaching, counseling, or therapy before? (if yes, explain)

3. What made you decide to seek coaching at this time?

4. Please tell about your family (marital status, children, etc.)

5. Please tell about your career or work background

6. Education and special training

7. Faith history

8. Current relationship with God

9. Do you ever find yourself sabotaging your own success? (yes, no, explain)

10. Are you willing to make changes in your life in order to fulfill your God given purpose?

11. Please describe three things in your life that give you the greatest joy

12. Over time, what three things have you found to be your greatest motivators?

13. What are you most passionate about?

14. Please describe what you feel God is doing in your life right now

15. Do you have any fears or insecurities with the coaching process? (If yes, describe)

16. Have you taken a Spiritual Gifts analysis? Describe what you feel are your strengths or gifts / talents

17. What one thing, if it were different or better, would make the greatest difference in your life right now?

Additional Comments

Jeffery J Horacek, O.D.

11115 Desert Creek Drive Blue Ridge, TX 75424

admin@jeffhoracek.com 214-842-9652 cell 972-752-9142 fax