Alignment Assessment Process

Alignment Assessment Form

Congratulations on choosing you! I am honored to be with you on your journey and I can’t wait to see the breakthroughs you will experience.

The purpose of the Alignment Assessment Process is to provide my team and I with additional information about you, your medical history and to get a really clear snapshot of your health and mindset.

This form includes about 60 questions (some are simple, and some are open-ended) and may take a generous amount of your time to complete so make sure you can commit to finishing once you begin.

Name *

First

Last

What name do you prefer to go by? *

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Marital Status *

Single
Married
Divorced

Emergency Contact *

Name, Phone Number, Relationship

Birthday *

Occupation *

Employer *

Doctor's Name *

Date of last check up

Are you currently seeing a licensed therapist (LPC, LCPC, LPCC, LMHC etc.)? *

What specific results would you like to get out of our time spent working together? *

Why is this important to you to get those results? How do you want to feel when you reach those results? *

How will you know when you are receiving value (i.e. – your money’s worth) from the Coaching process? *

What are the three biggest changes you want to make in your life over the next three years? *

What are the obstacles in your way that prevent you from achieving what you want? *

What are your habits/patterns that you repeat? Positive and Negative. *

i.e. Gym daily (1-2 rest days max), eat poorly when stressed of crunched for time, distractions, electronics & social media, when I've worked a ton I feel like being a homebody vs being out and about with my family, poor preparation for meetings when busy, lack patience with traffic, too critical, etc.

List 5 main fears: *

Father: *

Living
Deceased

Mother *

Living
Deceased

As a child in what ways were you punished by your parents? *

Give an impression of your home atmosphere when you were growing up. Include the state of compatibility between parents and between parents and children. *

Were you able to confide in your parents? *

If you have/had a stepparent, what was your age when your parent remarried?

Give a description of your religious upbringing (if any).

If you were not raised by your parents, who raised you, and between what years?

If you had to choose ONE, MOST IMPORTANT ISSUE to focus on in our time spent working together, what would it be and why? *

Describe how it is affecting your life also. (At least 100 words please) Example: “Anxiety because it keeps me from focusing on my work, making money, keeps me up at night and stops me from being present with my friends and family, etc.”

What outcome do you want to experience? (This is what you actually want, not what you don’t want) Please be specific. *

If you were completely free of this issue how would your life look? *

Please describe in positive terms so I can include all of the wonderful detail you include here in your personalised recording so it speaks directly to your subconscious the best possible. Be specific, the words and phrases you share are essential to the new beliefs you create. How would it impact your work? Your relationships? Your health? Your finances? Be as descriptive as possible.

What characteristics or qualities would you need to have to create the outcome you want? *

(i.e. committed, courageous, self-integral, responsible, powerful, bold, etc.)

Describe how you would feel if you no longer struggled with this issue, and what you want to feel. *

Describe what you would be doing if you had what you wanted and were no longer struggling with this issue. *

What’s your ultimate desire? What is your big dream and desire for your life? To feel free and financially secure? To travel the world with your partner? *

Don’t hold back! (Please be as detailed as possible with your answer.)

For this section, please fill in the blanks for the following Core Belief Audit Prompts...

I cannot expand to my full potential because: *

I cannot enjoy abundant love and relationship harmony because: *

I cannot expand to my full wealth potential because: *

I cannot expand to my full creative genius because: *

Last question! I would love to be able to serve and impact more clients just like you. Who else do you know that I should connect with right now?

Please write the names of 3 people (and their email address or phone number ) who might benefit from having a conversation with me.

Nice work, I’m proud of you! Click the button above to submit your form!