Work-Life Plan Discovery Form
The purpose of this intake form is to collect information on your work and life priorities, current state, and objectives. Upon completion, you have the option to book a session with an executive coach. The details of this form will be shared with the executive coach should you choose to book a call.
Name
*
First Name
Last Name
Email
*
example@example.com
Company Name
Job Title
What's the biggest challenge/interruption you are dealing with right now?
What's at stake if this challenge is left unaddressed?
What results are you hoping for in the next 12 months?
Back
Next
Career & Work-life
How would you rate your current job performance?
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
How effective are you in meeting your career objectives (e.g., promotions, skills development)?
Not Effective
1
2
3
4
Extremely Effective
5
1 is Not Effective, 5 is Extremely Effective
How well do you manage your workload and career-related stress?
Not Well
1
2
3
4
Extremely Well
5
1 is Not Well, 5 is Extremely Well
How satisfied are you with your level of influence and impact in your role?
Extremely Unsatisfied
1
2
3
4
Extremely Satisfied
5
1 is Extremely Unsatisfied, 5 is Extremely Satisfied
How important is career growth and progression to you?
Not Important
1
2
3
4
Extremely Important
5
1 is Not Important, 5 is Extremely Important
How significant is having a fulfilling and purpose-driven career?
Not Significant
1
2
3
4
Extremely Significant
5
1 is Not Significant, 5 is Extremely Significant
How critical is work-life balance in your career satisfaction?
Not Critcal
1
2
3
4
Extremely Critcal
5
1 is Not Critcal, 5 is Extremely Critcal
What is your primary career goal for the year? (e.g., achieve a promotion, improve leadership skills, change jobs)
Back
Next
Health & Wellness
How would you rate your current self-care practices (e.g., physical health, mental well-being)?
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
How effectively do you prioritize your personal needs amidst professional and personal responsibilities?
Not Effective
1
2
3
4
Extremely Effective
5
1 is Not Effective, 5 is Extremely Effective
How satisfied are you with the time you dedicate to relaxation, hobbies, and personal growth?
Not Satisfied
1
2
3
4
Extremely Satisfied
5
1 is Not Satisfied, 5 is Extremely Satisfied
How well do you manage stress and maintain emotional resilience?
Not Well
1
2
3
4
Extremely Well
5
1 is Not Well, 5 is Extremely Well
How important is self-care to your overall life satisfaction?
Not Important
1
2
3
4
Extremely Important
5
1 is Not Important, 5 is Extremely Important
How significant is maintaining your mental and physical health?
Not Significant
1
2
3
4
Extremely Significant
5
1 is Not Significant, 5 is Extremely Significant
How critical is it for you to feel energized and balanced?
Not Critical
1
2
3
4
Extremely Critical
5
1 is Not Critical, 5 is Extremely Critical
What is your primary self-care goal for the year? (e.g., establish a regular exercise routine, practice mindfulness, prioritize sleep)
Back
Next
Family & Relationships
How would you rate the quality of your relationships with family and friends?
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
How effectively do you balance work and personal life to nurture your relationships?
Not Effective
1
2
3
4
Extremely Effective
5
1 is Not Effective, 5 is Extremely Effective
How present and engaged are you in your family’s life?
Not Engaged
1
2
3
4
Extremely Engaged
5
1 is Not Engaged, 5 is Extremely Engaged
How well do you manage conflicts or challenges within your relationships?
Not Well
1
2
3
4
Extremely Well
5
1 is Not Well, 5 is Extremely Well
How important are your family and relationships to your overall well-being?
Not Important
1
2
3
4
Extremely Important
5
1 is Not Important, 5 is Extremely Important
How significant is having a strong support system in your life?
Not Significant
1
2
3
4
Extremely Significant
5
1 is Not Significant, 5 is Extremely Significant
How critical is emotional connection and support from loved ones to your satisfaction?
Not Critical
1
2
3
4
Extremely Critical
5
1 is Not Critical, 5 is Extremely Critical
What is your primary goal for your family and relationships this year? (e.g., improve communication, spend more quality time, resolve conflicts)
Back
Next
Financial Well-being
How well are you managing your personal finances (budgeting, saving, investing)?
Not Well
1
2
3
4
Extremely Well
5
1 is Not Well, 5 is Extremely Well
How satisfied are you with your current income and ability to generate wealth?
Not Satisfied
1
2
3
4
Extremely Satisfied
5
1 is Not Satisfied, 5 is Extremely Satisfied
How effectively do you advocate for your financial worth (e.g., salary negotiations, asking for raises)?
Not Effective
1
2
3
4
Extremely Effective
5
1 is Not Effective, 5 is Extremely Effective
How prepared are you for unexpected financial challenges (e.g., emergency savings)?
Not Prepared
1
2
3
4
Extremely Prepared
5
1 is Not Prepared, 5 is Extremely Prepared
How important is achieving financial independence to you?
Not Important
1
2
3
4
Extremely Important
5
1 is Not Important, 5 is Extremely Important
How significant is it for you to feel secure about your financial future?
Not Significant
1
2
3
4
Extremely Significant
5
1 is Not Significant, 5 is Extremely Significant
How critical is financial performance to your overall life satisfaction?
Not Critical
1
2
3
4
Extremely Critical
5
1 is Not Critical, 5 is Extremely Critical
How satisfied are you with your current ability to manage a work-life balance that supports your physical health?
Not Satisfied
1
2
3
4
Extremely Satisfied
5
1 is Not Satisfied, 5 is Extremely Satisfied
What is your primary financial goal for the year? (e.g., pay off debt, increase savings, invest more)
Back
Next
Working with an Executive Coach
After completing this form you may choose to book a call with our preferred executive coach.
Have you worked with an executive coach before?
Yes
No
Would you consider investing in one to help you achieve your goals now?
Yes
No
Not Sure
Anything else you would like to share with the executive coach so they can better assist you in the call?
Submit
Should be Empty: