Bregman Leadership Coaching Intake Form


This form is the beginning of your coaching process. Please don’t rush it. Sit comfortably with a cup of coffee or tea. Your responses will not only be helpful to your coach, it is likely that you’ll gain some insights that will be immediately useful to you. Complete the web form below, or download the form as a PDF (right-click this link and press Save Link As…) so you can take your time with it and not worry about losing your responses if your browser crashes.






1. Your Background

Tell me something about your personal background. Where you are from, where you grew up, something about your family, and any other details that you think will help me better understand and better support you.

2. Your Work

Tell me something about your work background. Where are you now and how did you get there? What are your key work goals? What is the most important thing you do in your work? What do you love about your work? What don’t you love about your work? What are you great at? What’s your edge?

3. Your Goals

Tell me about your top 1-2 LONG term goals; things that will take YEARS to accomplish. These should be things that you REALLY want, not what you SHOULD do.

What are 2-3 MEDIUM term goals; things that you would like to accomplish over the next year?

What are 2-3 SHORT term goals you want to achieve over the next 3-6 months?

What changes do you believe are needed for these short term goals to be accomplished easily?

What habits/activities/thought processes do you believe need to be dropped, simplified, or let go of to truly move forward?

4. Your Need

Why are you choosing to work with a coach? Why now? How can I be most helpful to you?

What might you do to sabotage yourself? What can I say to you when you are "stuck" that will return you to action?

5. Partnership

How you show up before, during, and after your coaching calls will make a big difference to the impact that coaching will have on your work and your life. Take a moment to reflect on the statements below and rate how true they are for you right now (1 is least true and 5 is most true).

I can be relied upon to be on time, prepared, and focused for all calls.
This is the right time for me to accept coaching.
I understand that it is my role to do the work necessary to get what I want in life. My coach’s role is to guide and support me.
I will follow through on the commitments I make to my coach.
I will give my coach the benefit of the doubt and "try on" new concepts or different ways of doing things.
I will speak straight (tell the whole truth) to my coach.
I am willing to feel uncomfortable feelings so that they do not sabotage my forward movement.
If I am not getting what I expect from my coach, I will ask for what I need.
I am willing to stop or change the self‑defeating behaviors which limit my success.
I have adequate funds to pay for coaching and will not regret or suffer about the fee. I see coaching as a worthwhile investment in my life.

7. Bonus

Is there anything else I should know that will help me help you?

<< Click here to go back to the Bregman Leadership Coaching page.

Questions? Contact: