Name:

Address (including city, state & zip):

Email Address:

Occupation:

How many hours per week do you currently spend at work?
20 or less 20-30 30-40 40-50 50-60 60+

Briefly describe your typical day.


What three things do you like about your life?


What three things do you dislike about your life?


What would you say are your three greatest accomplishments to date?


What major transitions have you made in the past 5 years (i.e., moved to
a new town, marriage, divorce, new job, etc.)?


What is the most difficult obstacle you have overcome?


On a scale of 1-10 how much stress do you have in your life? What is the
main area causing you stress (i.e., health related, financial, relationship, etc.)?


If resources (money, time, location, etc.) weren't an issue, what would you be, do, or have?


What are your primary goals in seeking assistance at this time? What, more
than anything, do you hope to gain from working with the life coach?

How did you hear about Susan Shapiro and Visionary Life Coaching?

Additional comments:

Best days and times for your complimentary consultation: