Life Coaching Assessment

Contact Details
Name*
First Last
Primary Phone*
Email*
Enter Email Confirm Email
Services I'm Interested in from Kyosei Coaching:*
- Life Coaching
- Career Coaching
- Inspired Retirement Coaching
- OTHER
(Check all that apply; if other, please specify)
... since you answered 'other,' what else can we help you with?*
How did you hear about us?*
What Blog?*
What Network Group referred you?*
What is the name of the person who referred you?*
Since you answered other, how did you find out about us?*
Work Status
What is your work status?*
- Employee
- Entrepreneur
- Freelance
- Student
- Unemployed
- Retired
- Preparing to Retire
Please select the option that most closely reflects your current work status.
What is your job title?*
Briefly describe your job.*
How long have you had this job / worked for this company?*
How long have you been unemployed?*
What are you studying?*
Please list your last five jobs and length of time you had them.*
Describe the key frustrations/challenges are you currently experiencing in your life and/or work?*
Please list up to five - one per line.

Survive

	Strongly Agree	Agree	Disagree	Strongly Disagree	Not Applicable
My income is currently meeting my basic financial needs.
I feel reasonably confident that this will continue.
I manage my money effectively.
My debt load is manageable.
I get adequate sleep and wake up feeling rested and refreshed.
I have healthy eating habits.
I (and those close to me) am (are) in good health.
I (and those close to me) am (are) free from depression, addiction, anxiety and/or other mental/psychological health issues.
I feel safe from threat of physical harm and/or mental/emotional abuse at work and at home.
At work, I feel like I fit in, belong, and am cared about as a person.
I have a support network of people I can trust, confide in and get support from at home.
I have a support network of people I can trust, confide in and get support from at work.
I am clear about what is expected of me at work.
I have the skills and knowledge I need to do my job.
I trust the expertise and decisions of my supervisor.
I have adequate insurance coverage to ensure theft, accidents, ill health and other unexpected events won't create undue hardship for me / my family.
The company I work for is struggling financially and/or is in the midst of a merger, downsizing or other major change.
My relationships are healthy, loving and supportive.
I feel like I have control over whether good or bad things happen to me.
I am the primary caregiver for one or more ageing parents.
My children still require a substantial amount of my time and energy.

Strive

	Strongly agree	Agree	Disagree	Strongly disagree	Not Applicable
I am clear on my company's strategic objectives.
I am clear on the key goals and objectives I am responsible to achieve.
I am clear on my own short and long term career objectives.
I have the skills and knowledge I need to achieve my goals.
My supervisor and co-workers support me to excel.
I receive recognition for my strengths and accomplishments.
I demonstrate good communication skills at work and at home.
I am able to focus and concentrate on the task at hand.
I make decisions with ease and confidence in my work and life.
I engage in regular daily and weekly planning.
I manage my time effectively.
I am clear on my priorities inside and outside of work.
I set and achieve personal and professional goals.
My work and home environments are optimally organized.
I create and use systems to enhance the quality of my life and work.
I am confident in my ability to achieve goals that are set out for me.
I have a strong support network.
I have a positive attitude.
I am receptive to hearing about my weaknesses and do my best to improve upon them.
I understand my strengths and weaknesses and how to leverage them.
I have adequate opportunities to learn and grow in ways that I enjoy both inside and outside of work.
I am able to endure short-term discomfort to reach long- term goals.
I rarely work long hours.
I feel satisfied with my career progress and achievements so far.
I feel satisfied with my financial status.
I have a concrete plan for managing my finances/investments and stick to it.

Strive - Planning to Retire

	Strongly agree	Agree	Disagree	Strongly disagree	Not Applicable
I am clear on my goals for the lifestyle I want to have in retirement.
I am confident I have set aside adequate finances to cover my retirement goals.
My significant other(s) and I speak about our plans for retirement and how they will fit together.
I am clear on the goals I want to achieve at work before I retire.
I am constantly adding to my list of things I plan to do when I retire.

Strive - Retired

	Strongly agree	Agree	Disagree	Strongly disagree	Not Applicable
I am clear on my goals for retirement.
I am confident I have set aside adequate finances to fulfill these goals.
I am confident in my ability to achieve these goals.
My significant other(s) and I speak about our retirement and how our goals are progressing.
I am satisfied with the progress I am making on my retirement goals so far.
My retirement is having a neutral or positive effect on my relationship with my significant other(s).
I have the opportunity to use my strengths in ways I enjoy everyday.
I have found a happy balance between feeling productive and feeling retired.
I feel satisfied with my financial status.
I am in good health and am confident that this will continue.

Alive

	Strongly agree	Agree	Disagree	Strongly disagree	Not Applicable
I have clear written set of values, standards and principles that I live by in life and work.
My work and home environments are aligned with these values and principles.
My primary relationships are aligned with and supportive of these values and principles.
I love my work.
I know my strengths and the areas of expertise I wish to use in my work.
I am happy with the amount of opportunity I have to use/develop these strengths in my work.
I get to express my creativity inside and outside of work to the degree I want to.
I know my mission/purpose in life and work.
My life and work are aligned with my mission/purpose.
I have a clear vision for my life and work.
I feel confident in my ability to realize my vision for my life and work.
My opinion is sought out and valued both inside and outside of work.
I actively pursue continuous learning and growth both personally and professionally. (You should be able to give specific, recent examples.)
I have above average health and enjoy my health and fitness routine.
I confidently express my authentic self in life and work.
I am easily able to discern which opportunities in life and work are a fit for me and which are not.
My home is a calming and energizing place to be.
My workplace is a focused, productive and energizing place to be.
I maintain a healthy balance between life and work.

Alive - Planning to Retire
Strongly agree Agree Disagree Strongly disagree Not Applicable
I have a clear understanding of my passions (values, strengths, purpose and vision) and a concrete plan for pursuing them in my retirement.

Alive - Retired

	Strongly agree	Agree	Disagree	Strongly disagree	Not Applicable
I have a clear understanding of my passions and a concrete plan for pursuing them in my retirement.
I love everything I am spending my time doing in my retirement.
I know my strengths and use them to energize myself on a daily basis.
I have a clear vision for my life in retirement and am confident in my ability to realize my vision.
My opinion is sought out and valued in retirement

Thrive

	Strongly agree	Agree	Disagree	Strongly disagree	Not Applicable
I love my work.
I love my life.
My life/work is aligned with all of my passions.
My relationships both inside and outside of work are highly functional and extremely satisfying.
My financial standing allows me to do everything that I dream of doing.
My passions, rather than my finances, influence my daily choices.
I am making a positive difference in the world through my life and/or work.
I am clear on the legacy I most want to make in my life and work.
I find it effortless to stay aligned with my purpose, values, and principles.
I identify and achieve my visions with ease.
I feel in integrity with my level of productivity and how I spend my time.
I am focused, energized and in the flow in all areas of my life and work.
I am excited to get up every day.
I easily make decisions that are in alignment with who I am.
I feel deeply connected to myself, my spirit, my family, and my community.
I feel deeply connected to a "higher power".
My daily choices support me in sustaining an optimal level of health.
My daily actions and decisions positively impact the well-being of my family, community and the environment over the long term.
I can't imagine doing anything other than what I am doing right now (because this is so much who I am).

Thrive - Planning to Retire
Strongly agree Agree Strongly disagree Disagree Not Applicable
I am excited about entering the retirement phase of my life.
Thrive - Retired
Strongly agree Agree Disagree Strongly disagree Not Applicable
I am leaving a positive legacy in my retirement.
I love being retired.
I am looking forward to the future.
Overall Self-Ratings
High Moderate Low
My Energy
My Passion for Life
My Passion for Work
My Success
My Health
My Relationships
My Confidence
What are the goals you would like us to help you achieve in your life and/or your work?*
List up to five.
Phone
This field is for validation purposes and should be left unchanged.

	Strongly agree	Agree	Disagree	Strongly disagree	Not Applicable
I am leaving a positive legacy in my retirement.
I love being retired.
I am looking forward to the future.

	High	Moderate	Low
My Energy
My Passion for Life
My Passion for Work
My Success
My Health
My Relationships
My Confidence

Contact Details

Work Status