Please share a little information about your background, current situation and goals/objectives desired from working with me. Note: this is entirely confidential. Nobody else will see this.

* 1. I found out about this program via:

* 2. My email address is

* 3. My name is:

* 4. Desired Objective: The primary reason you desire coaching is to improve what area of your life?

* 5. I have a real, priority goal I'd like to achieve within the next year

* 6. My Goal is ....

* 7. On a scale of 1 -10 my belief that I'm capable of achieving this goal is a ....

* 8. On a scale of 1-10 my commitment to achieving this goal in the next year is a....

* 9. Your current physical health is (scale 1-5, 5 being best)

* 10. What has been the greatest highlight of your life so far?

* 11. What is one of the lowest points of your life (optional- do not have to complete)

* 12. What is your greatest talent/ability (from a professional/value standpoint)

* 13. What would a best friend or parent brag about when they were talking about you

* 14. List 3 of your best habits

* 15. List 3 of your worst habits

* 16. If i achieve my goal within the next year I will feel...

* 17. If I do not achieve my goal in the next year I will feel....

* 18. The reason I want to join the GET UNSTUCK Program is...

* 19. I am interested in personalized, executive coaching from Martin and want to learn more.