New Client IntakeTo get started in a coaching relationship with Tom, complete this form in as much detail as possible. Name * First Name Last Name Email * Re-Enter Email * Phone Number * (###) ### #### Referred By Please tell me how you would evaluate the following areas of your life. Rank each area below from 1-5: 5 = I’m doing great! 4 = I’m doing well, but I could be doing better 3 = So-so 2 = Not so good 1 = Miserable! Learning New Things 1 2 3 4 5 Mood 1 2 3 4 5 Fitness 1 2 3 4 5 Family Harmony 1 2 3 4 5 Spiritual Development 1 2 3 4 5 Staying Connected With Friends and Relatives 1 2 3 4 5 Financial Security 1 2 3 4 5 Leisure Activities 1 2 3 4 5 Would you characterize yourself as introvert or an extrovert? Do you have a “mission statement”? If so, what is it? List three positive experiences that you find consistently exciting or enjoyable (e.g. 'I love to: watch a good football game/read a good mystery novel/jump out of airplanes/sign up a new client/find an elegant solution to a difficult problem.') If you had three wishes, what would they be? List up to three things that are currently causing you distress: What are you “just tolerating” in your life? What do you want more of? What do you want less of? Did you learn anything about yourself from doing this exercise? If so, what? Anything else you'd like to say? Thank you!