Thank you for taking the time to complete this brief survey. The purpose of this survey is to gather basic information about your interests, goals, challenges, and life/work balance. Should you choose to engage RElive Coaching services, your answers will clarify how we can best support you in your journey.

Please note that your identity and responses will remain strictly confidential.

As a thank you for your participation, RElive Coaching will offer you a one hour complimentary coaching session*.

* With ALL fields completed, only.

Your Full Name:
Your E-mail address:	Example: username@gmail.com
Country of Residence:	* - Please specify your Country

Your age:

25 - 34
35 - 44
45 - 54
55 - 64
65 - 85

Please select your age

MY WORK / LIFE BALANCE

1. Take a moment to reflect on how balanced your life feels to you right now. Choose one response that best describes your feelings:

I can usually maintain a healthy balance between my work life and my personal life
My work life and personal life are balanced some of the time
I usually feel overwhelmed by work and personal commitments
I don't usually make a clear distinction between my work life and personal life
I sometimes feel overwhelmed by work and personal commitments, but I have a strong support system

Please select at least one answer

2. How satisfied are you with the way you organize your time every day?

Very satisfied
Somewhat satisfied
Neither satisfied or dissatisfied
Somewhat dissatisfied
Very dissatisfied

Please select at least one answer

3. How satisfied are you with your level of control over your work life?

Very satisfied
Somewhat satisfied
Neither satisfied or dissatisfied
Somewhat dissatisfied
Very dissatisfied

Please select at least one answer

4. How often are you able to enjoy some time for yourself to relax or enjoy a hobby?

Often (at least three times a week)
Sometimes (at least once a week)
Rarely (less than once a week)
Never

Please select at least one answer

MY INTERESTS, GOALS AND DESIRES

5. Choose one career-related goal that best describes your current situation:

I am looking for advancement in my current career
I am looking to change my career path
I am generally happy in my current career
I am not sure if I should change my career path or not
Other: please specify

Please select at least one answer

6. How satisfied are you with how well you are able to meet a career-related goal?

(Goals can include things such as job hunting, taking a professional development course, sketching out a business idea, finding new professional networks, pursuing job advancement, etc.)

Very satisfied
Somewhat satisfied
Neither satisfied or dissatisfied
Somewhat dissatisfied
Very dissatisfied

Please select at least one answer

7. Choose up to three personal goals that best describe you:

I want to make positive changes in my personal relationships
I want to find a way to maximize my talents and passions
I want to learn how to overcome feelings of self-doubt
I want to improve the way I set and accomplish my daily goals
I want to feel more empowered by my accomplishments
I want to achieve better balance between my work and my personal life
I want to expand my social network
Other: please specify

Please select up to three choices

8. How satisfied are you with how well you are currently able to meet a personal goal?

Very satisfied
Somewhat satisfied
Neither satisfied or dissatisfied
Somewhat dissatisfied
Very dissatisfied

Please select at least one answer

MY CHALLENGES & UNCERTAINTIES

9. Choose up to three responses that best describe you:

I sometimes have trouble managing my time
Sometimes my need for perfection gets in the way of completing a project
I sometimes feel overwhelmed by negative self-talk
I sometimes find it difficult to say 'no'
I sometimes have trouble breaking my goals down into manageable tasks
I sometimes struggle with prioritizing my work goals and my personal goals
I sometimes struggle with asserting my ideas in my work environment
Other: please specify

Please select up to three choices

10. Choose up to three responses that tend to cause the most anxiety for you:

Making a major change in my life
A lack of time to complete my tasks/goals
Meeting new people
Presenting my ideas to people
Starting a new project
Voicing my opinion
Setting boundaries with friends /family
A competitive work environment
Other: please specify

Please select up to three choices

RElive Coaching can help ...

11. Life coaching is designed to support and empower you in your life journey. If you had an opportunity to work with a Life Coach, what would be your highest priority? Please choose one:

Career change
Work/life balance
Coping with a life transition
Personal development
Clarifying my goals
Other: please specify

Please select at least one answer

12. Have you ever worked with a Life Coach?

Yes
No

Please select Yes or No

If yes, what do you feel was the most helpful thing about the experience?

OPTIONAL

13. Do you have any specific questions or concerns about the life coaching process that we could address for you, either via email or in your complimentary consultation session?