The Solution Tap
Please tell me about yourself before we start.
Name: __________________________________________________________________________________
Last First Middle Initial
Date of Birth: ____/____/________ Age: ___________ Gender: Male Female
Marital Status: (Circle your answer.)
Never Married/Single Domestic Partnership Married
Separated Divorced Widowed
Name of Spouse: ________________________________________________________________________
Last First Middle Initial
Names and Ages of any Children: 1.
2. 3.
4. 5.
Occupation: _______________________________ Highest Level of Education: _______________
Address: ___________________________________________________________________________________
Street with Number
___________________________________________________________________________________________
City State Zip Code
Home Phone: ____________________________ Cell/Other Phone: _________________________
Email: ___________________________________
Which are the best ways to get hold of you?
1. _______________________________________
2. _______________________________________
How did you hear about me? ______________________________________________________________
Who, if anyone, referred you? _____________________________________________________________
Can I make a thank you contact? (I will not disclose your identity.) Yes No
Are you currently employed? Yes No
If yes, what is your current employment situation? ___________________________________________
____________________________________________________________________________________________
Do you enjoy your work? ____________________________________________________________________
Is there anything stressful about your work? _________________________________________________
____________________________________________________________________________________________
Do you consider yourself to be religious or spiritual? Yes No
If yes, please answer the following:
Describe your faith or belief: ________________________________________________________________
Do you attend church? Yes No
If so, what church do you attend: ____________________________________________________________
How does your faith or spirituality influence your everyday life?
What do you value most in your life?
What would you like to accomplish in our work together?
What do you consider to be the barriers to achieving your desired goal(s) or outcome(s)?
What do you consider to be your strengths?
What do you consider to be your weaknesses?
What are your long-term goals for the next 5 years?
What are your short-term goals for the next 3 months?
Do you have other areas of your life that you want to change or improve? If so, what do you want to change or improve?
i.e. intimate relationship(s)?
Your relationship with yourself? (How you see yourself, treat yourself, trust your judgment/feelings/instincts):
Other relationships? (Immediate family, friends, people at work, extended family?)
Home and/or work environments?
Career?
Fun and leisure?
Finances?
Spiritual life?
Health?
Is there anything else you want me to know before we start?
How Coachable are you?
Circle the number below that most closely represents how true each statement is for you now. These questions will help you and me discover how coachable you are at this time.
1 equals less true. 5 equals consistently true.
1 2 3 4 5 I will consistently be on time for scheduled meetings, and if needed, contact the coach to reschedule.
1 2 3 4 5 I will come to our sessions with an agenda or idea about how I would like to use our time together.
1 2 3 4 5 I am fully willing to do the work required to achieve my goals.
1 2 3 4 5 If asked, I will commit to writing 30 minutes a day first thing in the morning.
1 2 3 4 5 I am willing to try out new behaviors or new ways of thinking.
1 2 3 4 5 I will be completely truthful with my coach.
1 2 3 4 5 I am willing to stop or change self-defeating behaviors.
1 2 3 4 5 I can financially afford coaching without going into debt.
1 2 3 4 5 I am not dependent on substances that alter my ability to think clearly and always behave responsibly, or I am in recovery and receiving the support I need.
Regarding the last question: If family or friends have expressed concern about your usage of addictive substances (alcohol, street drugs, prescription drugs) you may have a substance dependence problem.