Life Assessment

Life Satisfaction Questionnaire

Build your dream and overcome the nightmares
Full Name

First NameLast Name
E-mail
example@example.com
Phone Number
How satisfied are you with different areas of your life?
Select a number from 1-5 next to each of the following areas of life. If you give an item a 1, you are completely dissatisfied with this part of your life. It means, “This part of my life is entirely unacceptable to me in its current state.” A number 5 means, “I couldn’t be happier or more satisfied with this area of life.” Your overall satisfaction will change from day to day, but try to give an overall assessment of where you are at present.
Physical Health Mental/Emotional

1

2

3

4

5

1 is Worst, 5 is Best
Health Career/Employment

1

2

3

4

5

1 is Worst, 5 is Best
Satisfaction Financial Stability

1

2

3

4

5

1 is Worst, 5 is Best
Marriage/Romantic Relationships

1

2

3

4

5

1 is Worst, 5 is Best
Home Life (Immediate Family)

1

2

3

4

5

1 is Worst, 5 is Best
Extended Family (Relatives, In-laws) Friends/Social

1

2

3

4

5

1 is Worst, 5 is Best
Life Recreation/Relaxation/Leisure

1

2

3

4

5

1 is Worst, 5 is Best
Lifestyle (Degree of Busyness and Life Balance)

1

2

3

4

5

1 is Worst, 5 is Best
Personal Life Fulfillment

1

2

3

4

5

1 is Worst, 5 is Best
Spiritual Health/Life

1

2

3

4

5

1 is Worst, 5 is Best
Church/Religious Life

1

2

3

4

5

1 is Worst, 5 is Best
Physical Comfort (Housing, Neighborhood, Possessions, Cars, etc.)

1

2

3

4

5

1 is Worst, 5 is Best
1. Why do you want coaching? Be as specific as possible. Example: “I want to start an exercise program to gain more energy and to lose 30 pounds.” Use extra paper if you wish.
2. Are you or have you ever been in counseling or therapy? Yes No If yes, please explain.

YesNo
Explanation
3. Describe your spirituality. What is your relationship with God? In what ways do you sense God might be challenging you, nudging you in a different direction, or trying to get your attention.
4. What are the most important things (good and bad) happening in your life right now?
5. In what ways would you like your life to be different one year from now? Be specific.
6. What is getting in the way of these goals?
7. How might you sabotage yourself as you work toward your goals, or how might you sabotage me as your coach?
8. List at least three things you procrastinate at -- the things that you’ve been putting off.
9. What, if any, are your concerns about coaching?
10. Rate the level of stress in your life on a scale of 1 to 10. (1=low and 10=high)
11. What are your primary stressors?
12. Why did you select me as your coach?
13. What would you like me to do if you get behind in progress toward your goals?
14. How do you like to be supported or held accountable?
15. What else would you like me to know about you?
Should be Empty:

Life Satisfaction Questionnaire