Personal Performance
Coaching Questionnaire

Please complete this form- We are excited to learn how we can assist with improving your performance

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* 1. Your Contact Information

Client Name: *

Company:

City/Town:

Country: *

Email Address: *

Phone Number: *

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* 2. Your Age

12-17

18-21

22-29

30-39

40-49

50-59

60-64

65+

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* 3. Your Marital Status

Single

Married

Partnered

Separated

Divorced

Widowed

Other

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* 4. Your Occupation

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* 5. Rate yourself on a scale of 1-10 in each of the following areas. 1 being, that you have NOT made any progress in this area and 10 being that you are RIGHT where you think you should be by this stage in your life?

	1	2	3	4	5	6	7	8	9	10
Health	Health 1	Health 2	Health 3	Health 4	Health 5	Health 6	Health 7	Health 8	Health 9	Health 10
Finance	Finance 1	Finance 2	Finance 3	Finance 4	Finance 5	Finance 6	Finance 7	Finance 8	Finance 9	Finance 10
Career	Career 1	Career 2	Career 3	Career 4	Career 5	Career 6	Career 7	Career 8	Career 9	Career 10
Relationships	Relationships 1	Relationships 2	Relationships 3	Relationships 4	Relationships 5	Relationships 6	Relationships 7	Relationships 8	Relationships 9	Relationships 10
Emotions	Emotions 1	Emotions 2	Emotions 3	Emotions 4	Emotions 5	Emotions 6	Emotions 7	Emotions 8	Emotions 9	Emotions 10
Time Management	Time Management 1	Time Management 2	Time Management 3	Time Management 4	Time Management 5	Time Management 6	Time Management 7	Time Management 8	Time Management 9	Time Management 10

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* 6. Pick 3 of the above categories that you want to change and/or improve.
In the space below, explain what would have to happen in order to take each of these 3 areas to a level “10” experience?

1st category change

2nd category change

3rd category change

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* 7. What is the PAY OFF for achieving these goals? How is your new life going to be different? What is the upside or the reward for following through on these goals?

1st category rewards

2nd category rewards

3rd category rewards

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* 8. What beliefs, fears and/or patterns of behaviors have prevented you from already achieving these goals?

1st belief or fear

2nd belief or fear

3rd belief or fear

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* 9. What is the COST or the Negative Consequences for not following through? What is your life going to be like if you continue to buy into your excuses, patterns and fears?

1st consequence

2nd consequence

3rd consequence

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* 10. Why are you a good candidate for our coaching and how do you think you will be able to benefit from a coaching program like this?

1st reason/benefit

2nd reason/benefit

3rd reason/benefit

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* 11. What type of coaching are you looking for?

Performance Coaching

Accountability Coaching

Mindset Coaching

Business Coaching

Other (please specify)

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* 12. How did you learn about coaching with Jairek?

Please click "DONE" below to submit your answers.

Note from the SUCCESS team: Congrats on taking the first step towards seeing Rapid Results in your life and business, and THANK YOU for filling out this questionnaire!

After reviewing your answers, a SUCCESS coach will reach out to set up a day & time for your complimentary discovery coaching session to ensure we match you with the best SUCCESS coach on our team for your current goals and focus.

Have a fantastic day!

To your success,

Jairek Robbins
President of SUCCESS Enterprises

Question Title

* 1. Your Contact Information

Question Title

* 2. Your Age

Question Title

* 3. Your Marital Status

Question Title

* 4. Your Occupation

Question Title

* 5. Rate yourself on a scale of 1-10 in each of the following areas. 1 being, that you have NOT made any progress in this area and 10 being that you are RIGHT where you think you should be by this stage in your life?

Question Title

* 6. Pick 3 of the above categories that you want to change and/or improve. In the space below, explain what would have to happen in order to take each of these 3 areas to a level “10” experience?

Question Title

* 7. What is the PAY OFF for achieving these goals? How is your new life going to be different? What is the upside or the reward for following through on these goals?

Question Title

* 8. What beliefs, fears and/or patterns of behaviors have prevented you from already achieving these goals?

Question Title

* 9. What is the COST or the Negative Consequences for not following through? What is your life going to be like if you continue to buy into your excuses, patterns and fears?

Question Title

* 10. Why are you a good candidate for our coaching and how do you think you will be able to benefit from a coaching program like this?

Question Title

* 11. What type of coaching are you looking for?

Question Title

* 12. How did you learn about coaching with Jairek?

* 6. Pick 3 of the above categories that you want to change and/or improve.
In the space below, explain what would have to happen in order to take each of these 3 areas to a level “10” experience?