Creating Fulfillment in Your Life In our coaching together, our goal is to support and empower you to create a more fulfilling life and career.Please fill out the following scale to help us assess your current situation and determine the most important areas to work on. Current Satisfaction Assessment: Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Rate each area from 1 – 10, using # 1 as the lowest level of satisfaction and # 10 as the highest level of satisfaction.Career *Rate 1 out of 10Rate 2 out of 10Rate 3 out of 10Rate 4 out of 10Rate 5 out of 10Rate 6 out of 10Rate 7 out of 10Rate 8 out of 10Rate 9 out of 10Rate 10 out of 10Significant Other *Rate 1 out of 10Rate 2 out of 10Rate 3 out of 10Rate 4 out of 10Rate 5 out of 10Rate 6 out of 10Rate 7 out of 10Rate 8 out of 10Rate 9 out of 10Rate 10 out of 10Family *Rate 1 out of 10Rate 2 out of 10Rate 3 out of 10Rate 4 out of 10Rate 5 out of 10Rate 6 out of 10Rate 7 out of 10Rate 8 out of 10Rate 9 out of 10Rate 10 out of 10Friends *Rate 1 out of 10Rate 2 out of 10Rate 3 out of 10Rate 4 out of 10Rate 5 out of 10Rate 6 out of 10Rate 7 out of 10Rate 8 out of 10Rate 9 out of 10Rate 10 out of 10Physical Health and Well Being *Rate 1 out of 10Rate 2 out of 10Rate 3 out of 10Rate 4 out of 10Rate 5 out of 10Rate 6 out of 10Rate 7 out of 10Rate 8 out of 10Rate 9 out of 10Rate 10 out of 10Emotional Health and Well Being *Rate 1 out of 10Rate 2 out of 10Rate 3 out of 10Rate 4 out of 10Rate 5 out of 10Rate 6 out of 10Rate 7 out of 10Rate 8 out of 10Rate 9 out of 10Rate 10 out of 10Physical Environment *Rate 1 out of 10Rate 2 out of 10Rate 3 out of 10Rate 4 out of 10Rate 5 out of 10Rate 6 out of 10Rate 7 out of 10Rate 8 out of 10Rate 9 out of 10Rate 10 out of 10Finances *Rate 1 out of 10Rate 2 out of 10Rate 3 out of 10Rate 4 out of 10Rate 5 out of 10Rate 6 out of 10Rate 7 out of 10Rate 8 out of 10Rate 9 out of 10Rate 10 out of 10Spirituality/Religion *Rate 1 out of 10Rate 2 out of 10Rate 3 out of 10Rate 4 out of 10Rate 5 out of 10Rate 6 out of 10Rate 7 out of 10Rate 8 out of 10Rate 9 out of 10Rate 10 out of 10Education/Personal Growth *Rate 1 out of 10Rate 2 out of 10Rate 3 out of 10Rate 4 out of 10Rate 5 out of 10Rate 6 out of 10Rate 7 out of 10Rate 8 out of 10Rate 9 out of 10Rate 10 out of 10Fun and Leisure *Rate 1 out of 10Rate 2 out of 10Rate 3 out of 10Rate 4 out of 10Rate 5 out of 10Rate 6 out of 10Rate 7 out of 10Rate 8 out of 10Rate 9 out of 10Rate 10 out of 10Lifestyle *Rate 1 out of 10Rate 2 out of 10Rate 3 out of 10Rate 4 out of 10Rate 5 out of 10Rate 6 out of 10Rate 7 out of 10Rate 8 out of 10Rate 9 out of 10Rate 10 out of 10Balance in Life *Rate 1 out of 10Rate 2 out of 10Rate 3 out of 10Rate 4 out of 10Rate 5 out of 10Rate 6 out of 10Rate 7 out of 10Rate 8 out of 10Rate 9 out of 10Rate 10 out of 10Describe in more detail 1 to 5 areas you’d most like to focus on.Area 1 *Area 2 *Area 3Area 4Area 5If you could create the results you desired in these 1 to 5 areas, what specifically would you like to achieve in the next 90 days?What would you have to do or change to make these things happen in the next 90 days.As a coach, how can I best support you to achieve your goals?CREATING FULFILLMENT IN YOUR RELATIONSHIPS What is your timetable for making those changes? Our work together is tailor-made to meet your needs. Please check those areas that most apply to you. Conflicts with a friend, family member, or co-worker Enhancing or improving relationships with spouse, children, family or friendsResolving issues in a relationshipBeing a better parent/spouse/siblingFears and insecurities around relationships Communicating more effectively what I need Setting boundaries and saying no Looking for the love of my lifeNeed for dating coaching Having closer friendships or greater sense of communityCreating new friendships Parenting issues Creating quality time for relationships OtherIf Other, please specify:What specifically would you like to achieve in the next 90 days with your relationships? CREATING OPTIMAL HEALTH Our work together is tailor-made to meet your needs. Please check those goals below that you would most like to focus on. Lose weight Reduce or eliminate pain Improve my diet Get off sweets or junk food Improve my exercise regimen Recover from an illness or other health challenge Redesign my life now that I’ve had an injury or illnessImprove my energy levelFeel more comfortable with my body imageLower my blood pressure Feel more flexible and improve my mobility Be able to do some things physically that I used to be able to do Get in shape to prevent or avoid___OtherWhat are you wishing to prevent or avoid?If "Other," please specify:What is your timetable for making those changes?What specifically would you like us to achieve in the next 90 days with your health? MANAGING LIFE TRANSITIONS Our work together is tailor-made to meet your needs. Please check those issues that most apply to you. Unclear about what’s nextNot sure who I am anymore Feelings of loss Fear of moving forward My self-image or self-esteem is not what is was because of what happened My faith is shaken because of what happened Feeling fearful and insecure about the futureExcited to create a “New Me” Opportunity to explore new interests Excited for new opportunities to grow Opportunity to finally focus on my dreams and goals OtherIf Other, Please Specify:What is your timetable for making those changes? What specifically would you like to achieve in the next 90 days with your life transitions?PhoneSubmit