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Your name and surname

You company/organisation/ department

Your occupation/ professional role/position

Your age

Birth date

Your religion (optional)

Email address

Cell no

Landline

Personal Assistant (PA) contact detail

Should we schedule appointment with you directly or with your PA

1. How would you describe yourself (at least 5 characteristics)?

2. What drives you in life? (Your choices, your actions, etc.).

3. What energises you and how do you retain your energy levels?

4. What drains you and how do you get out of it?

5. List your 5 major achievements of the past 12 months that you are most proud of? (In any aspect of your life).

6. On the flip side … have you had any major disappointments over the same period?

7. What problems or concerns have taken most of your attention over the past 12 months?

1. Where and/ or how do you want to be in the next 5 to 10 years? What is your future personal vision?

2. What do you believe you are called for? or what is your sense of purpose? (Your mission…)

3. What are you passionate about in life?

4. What values do you uphold? (What do you stand for? What is most important in your life) Please list in order of priority.

5. How do or would you define success?

1. What is your expectation of the coaching programme?

2. Can you list specific objectives/outcomes that you would like to achieve in the coaching programme? In order of priority.

3. Do you have previous experiences with coaching? What type?-(executive, team/group, life/personal )YES/NO

4. How will you know that the coaching programme has been beneficial? Please list your success criteria.

1. Are you on a training course? If so nature and status? Where? With whom?

2. Are you in a mentoring relationship? If so, at work or outside of work? Formal or informal?

3. Are you seeing a therapist or counselor? YES/NO

4. Are you on any medication at this point in time? YES/NO- if so for what?

5. Anything else your coach should know?