Questionnaire Form – Dr. Clarice Fluitt

Please complete the following Assessment in detail. This assessment is intended to provide a bridge which is essential for your continuing success in launching you from where you are to where you want to be.
Please complete the following Assessment in detail. This assessment is intended to provide a bridge which is essential for your continuing success in launching you from where you are to where you want to be.
Please select one focused area you would like to be more effective in and apply the following questions to your selection.*
- Professional
- Public Speaking
- Spiritual
- Family
- Friends
- Financial
- Health
- Emotional
- Recreational
Name*
First Last
Email*
Phone*
BECOMING THE PERSON I NEED TO BE
Describe in detail three (3) things you need to change to improve your success:*
One specific area I need to see improved in my life is:*
One goal I really want to achieve is:*
VISION & GOALS
What are the biggest goals you want to achieve in the next 12 months?*
What key lifestyle changes would you like to implement and achieve?*
What is the overall vision for your life as you see it today?*
What is the key outcome you would like to achieve from this mentoring/coaching?*
(Please do not hold back on this question. Make your outcome so big that if you were to achieve it, your decision to receive coaching from Dr. Clarice Fluitt would be the single most important decision you ever made in your life.)
What specific actions are you willing to commit to in order to work toward completing your goal?*
What is your estimated timeline toward completing your goal?*
Can you think of any roadblocks that could possibly get in the way of your ability to accomplish this goal?*
What specific actions can you take to overcome these roadblocks? By when?*
Why is accomplishing this goal important to you?*
Specifically, what benefit will you gain?*
PERSONAL BACKGROUND
What major transitions have you had in the past two years; for example, entering or approaching a new decade of life, a new relationship, a new job, a new role, a new residence, changes in children’s ages or stages of life, separation, divorce, death of a loved one, birth of a child, marriage, etc.?*
What do you consider to be your greatest accomplishments?*
Who are your role models?*
How have you overcome past challenges or difficulties in your life?*
Do you have repeating patterns or habits in your life you would like to change?*
Are there situations or people in your personal or business life that do not reflect your values?*
POTENTIAL AND POSSIBILITY
What do you consider to be your strengths and greatest attributes?*
What do you value most in life?*
What do you always find time for?*
If you had all the money and resources needed, what would you be doing with your life?*
Do you have any regrets? If so, what are they?*
Describe your life exactly the way you want it to be in two years from now. Be very specific.*
What would you like to contribute to the world to make it a better place?*

Your success during our time will be increased as you take notes and act on the things you say you will do to experience a fresh dimension of reality in your life.

I am looking forward to working with you to help you cultivate a life of greatness!

Committed to your success,

Dr. Clarice Fluitt