Personal Survey – Roadmap for the Treasure Hunt

The questions contained in this form will assist us in exploring the things that are important to you. Without this information, we would exhaust several months of coaching just to establish the baseline achieved from completing this survey. Areas to fill in are noted by: ‘Click here to enter text.’

As you respond to the questions, you will experience judgments, thoughts, and emotions surfacing while you explore your answers. All I ask is that you do your best and respond where you have answers. Just answer them as though you were having a conversation in the mirror.

All of the information recorded in this form is bound by the same confidentiality requirements that apply to all communications between you and me. If you have any questions regarding those policies please communicate those concerns to me immediately.

When the form is complete, scan and email the file to me. I want to provide you with the highest level of coaching possible by customizing my efforts toward what is important in your life. To do my best for you, I require ample time to review your responses, so please plan on returning the completed document no later than 48 hours before your orientation.

Now that you’ve received this form, it means you’ve committed to at least some life coaching. During that period, you are expected to set and keep your appointments or notify me at least 24 hours in advance to reschedule.

Procrastination is not a part of this program. It is up to you to schedule your appointments with me at least one week in advance. I am flexible in meeting your needs regarding the specific time.

Please fill out and email to me at the address below.

Follow up with a phone call to set up your appointment, please.

Email: Coach@BeTheDream.com

Enjoy the journey…I'll see you on the other side.

Lead with Vision,

Zen Benefiel – Your Possibilities Coagulator

Client Intake Information

Client Name: Click here to enter text.

Birthdate: Click here to enter text.

Country of Origin: Click here to enter text.

Confidentiality

The issue of confidentiality is paramount to this relationship. Nothing in this relationship will be discussed outside of our conversations. There are times when references to others may be helpful, however I would not ever mention a name or person that would lead someone to infer the discussion was about you as a client.

PLEASE indicate your comfort level with this level of confidentiality and express your concerns in the space below if the above stipulation is insufficient to assure confidentiality.

Place your comments here:

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Intake Interview

As a coach, it is important for me to understand how you view the world in general and yourself in particular. Each person has a unique way of thinking and a unique way of interacting with others.

Please answer each of the following questions as clearly and thoughtfully as possible, expressing the best of who you are now. It may take more space than provided. Be as detailed as possible. These are ‘pondering’ questions designed to stimulate your thinking in a particular way that will make our work together even more productive.

I suggest that you take several days to compose your responses to these questions. Sometimes people like to work alone. If you decide not to use my services, this will give you a starting point for your own process.

Thank you and have fun!

1. What accomplishments must, in your opinion, occur during your lifetime so that you will consider your life to have been satisfying and well lived – a life of few or no ‘regrets.’

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2. If there were a secret passion in your life, what would it be? Consider your dreams and goals for life.

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3. What do you consider your role to be in your local community? In your country of residence? In the world? If you haven’t considered these items, how would you like to be involved?

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4. If you could devote your life to serving others, and still have the life style you need, would you do it? How would it look?

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5. If you trusted your coach enough to tell him or her how to manage you most effectively, what tips would you give?

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6. If you had a five-year goal and had continuing services of a coach to help you make it happen (money not an issue), what would that goal be? What difference would a coach make? How would it affect your progress?

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7. What is missing in your life that you know of now? What would make your life more fulfilling?

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8. Do you believe in God or in the concept of a higher power? If so, describe the most useful and empowering aspects of your relationship. If you have a different point of reference, what is it and how do you use it?

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9. Have you recognized the connectedness between your beliefs, morals, and values and the ethics (actions you take) that result in creating your reality? Think about some of your most problematic issues and their resolution for a moment. What were the key factors in your decisions?

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10. If you were able to create the life you desire, what do you most desire to change right now? How would you do it? What feelings are associated with those thoughts?

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11. Imagine that your coach is sitting in front of you, totally supportive of your desire to change and knowing the key elements that can assist you. What would they tell you now?

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12. Based on your knowledge of yourself, what are the key components you need in a future vision of your professional work?

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13. What are the areas of inquiry or industry you feel most qualified to seek employment or create opportunity? Why?

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Primary Focus and Action Plan

Please identify five areas that you want held as your main focus. For each focus area provide a simple heading and a description of a measurable result, including details and timeline.

Example:

1. Client follow-up

I have a system to follow up on calls and letters.

I have realistic goals for making contacts and follow up.

My monthly income increases by X dollars.

I have X more hours available for family/friends.

I get all tasks accomplished.

I feel better about myself.

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By DateClick here to enter text.

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Today’s date Click here to enter text.

What do you think about the above – your honest assessment?

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Inner Awareness

These questions are designed to help you look upon your current activities from an observer’s point of view. How you see yourself is as important as the accomplishments you make. Please be as honest and in-depth in your answers as possible, and then go a little deeper into your self-view.

1. How often do you feel or perceive things in your immediate environment or when considering taking actions? What internal process do you have in dealing with these impressions?

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2. What methods do you currently use to ‘check in’ with others in your relationships? How do you know that you are receiving valid feedback and getting a clear picture of situations?

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3. What would you say is your worst, your best, and how you could improve your communications with others to establish more clarity and openness in your relationships?

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4. What internal processes provoke self-condemnation? What secrets do you keep about yourself?

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5. What would revealing your secrets cause to happen in your life now? How would they affect your relationships in a positive way? How would you benefit?

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6. What are your current ‘coping strategies’ and how would you like to change them, if at all?

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Education and Skill Set

Please check of the appropriate level:

Education: High School___ BA/BS___ MA/MS___ Law Degree/, Ph.D._____ CPA____

General health & well-being: (Describe)

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Have you worked with a coach? Click here to enter text.

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Have you worked with a counselor/therapist?Click here to enter text.

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Please list whether you have taken the following assessments and your scores – Links provide free assessments if you are interested.

Meyer-Briggs: result (ex: INTJ)Click here to enter text.

DISC:	result (Natural/Adaptive) Click here to enter text.

Enneagram: result(Personality Type) Click here to enter text.

Kolbe: yes/no	result (Your Index) Click here to enter text.

NLP Processing Styles in order Click here to enter text.

Relationship Status:

Single ___ Married___Divorced___Widowed___Significant other____

Comments:

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Personal Reflection

My strengths are: (descending order of importance)

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My weaknesses are: (descending order of iClick here to enter text.mportance)

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Issues and situations that limit me or hold me back are: (i.e., unhealthy relationships, recurring problems, unproductive habits, disorganization, etc.).

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What I love to do is:

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What I tend to do myself is:

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What I tend to delegate to others is:

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What I dislike doing and successfully avoid is:

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What I dislike doing but still do regularly is:

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The changes that I have attempted without success in the past are:

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My top 5 goals for the next 3-6 months are:

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My top 5 goals for the next two years are:

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My top 5 goals for my lifetime are:

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The Clichés or axioms that are in my life regarding my guiding principles are:

(In other words, what statements of principle influence my life?)

Example: Treat others the way that you would want to be treated. People are innocent until proven guilty. I don’t trust anyone, they have to earn my trust.

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Where I can use support is:

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How others perceive me – the reputation I have is:

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How I want to be perceived:

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Important accomplishments of my life are:

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When I am at my best, the way it looks, feels and sounds is:

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If I could change anything I would change:

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My Skills Set (from Checklist or Resume)

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EXPECTATIONS:

Coach Benefiel promises that all Coaching Guidelines and the Professional Code of Ethics will be maintained and information provided by the client to the coach will be kept strictly confidential. Throughout the working relationship the coach will engage in direct and personal conversations. The client understands that the power of the coaching relationship can only be granted by the client and the client agrees to follow agreements to make the coaching relationship powerful.

I’d like to share with you what my expectations of you, the coach, are from my perspective as the client.(examples; be on time for the scheduled appointment; give 24 hour cancellation notice; be committed to your professional development, etc.)

I expect that you as my coach will:

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As a coach, I want you to be: (i.e., interaction style: gentle, challenging, proactive, etc.)

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The results I intend to create from our work during the next 3-6 months are:

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When I feel supported, it looks like: (What would support feel like to you?)

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Comments: (Please note other points important for me to understand as your coach)

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Multiple choice questions Circle one answer to each question:

1) When I am working on a project, the part I prefer to do is:

a) Initiate, inspire, create, get it started, see the possibilities

b) Integrate the various components, support/work with others, provide details

c) Get working on it, promote results, produce action, keep motivated

d) Analyze it, direct it, perfect it, finish it, wants the proof

2) When I am working on a project, the way I respond to new projects is:

a) Great, how do you want it done!

b) Is there a problem? Do we really need to do that? What did we do last time?

c) Ok, you do this and I’ll do that.

d) Who did it last time? Whose responsibility is it?

3) When I am my “best” self, people see me as:

a) Hopeful, inspired, cheerful, bright, animated

b) Calm, teammate, nurturing, fair, relaxed, subtle

c) Active, go-getter, multitasker, dynamic, confident

d) Accomplished, secure, stable, striking, firm

4) When I am my “worst” self, people see me as:

a) Flighty, airhead, “Pie-in-the-sky”, dreamer

b) Wishy-washy, people-pleaser

c) Pushy, abrupt

d) Cold, hard, stubborn

5) For best results, I prefer to:

a) Take the easier route.

b) Remain connected with others.

c) Do it your way.

d) Finish it correctly.

In the following questions, choose three (3) answers per question. Please rank them in order of importance, (3) being the most important, (1) being the least important.

1) Which one of these descriptions most closely describes the center of who I am:

a) Perfectionist, thinking and doing right, expectations of others

b) Giver-Helper, caregiver

c) Achievement, productive, competitive

d) Looking for connection (love), emotionally sensitive, moody

e) Observer, private, detached

f) Procrastination, questioning, suspicious, discovering diversity

g) Charming, planning, intellectualizing, wanting to be stimulated

h) The boss, controlling, concerned with justice & power, truth-seeker

i) Mediator, ambivalence about personal decisions, hard to initiate change

2) In relation to time, I find meaning in:

a) Making today the way it should be

b) Responding to the needs of today

c) Working toward future goals

d) Revering the past

e) Reflecting on past experiences

f) Making the most of today

g) Working on future plans

h) Working to make the future just and fair

i) Preserving the past

3) Most important to me is to:

a) Change the world

b) Develop friendships

c) Be successful & help others to be successful

d) Be loved

e) Share my knowledge of life

f) Be serene and grounded - secure

g) Provide optimism and enthusiasm

h) Be direct and compassionate

i) Live in peace with others

Other comments:

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Congratulations! You have completed the Coaching Intake Information.

Thank you! I trust you garnered some insights along the way that will help us craft your plan.

Please send your completed form to me via email…. Coach@BeTheDream.com