The following is a quick and easy self-assessment tool that
can help you determine if you would benefit from coaching.
The form asks questions about a number of different domains
of your life, both professional and personal.

As you answer the questions, notice which questions you respond to with “struggle with this” or “needs work”. These
are all areas in which coaching would be beneficial.

After you complete the assessment, you can send the results
to our office and we will contact you to set up a complimentary
coaching session. In your session we will have an opportunity
to review your self-assessment form and you will receive coaching in any area of your personal or professional life.

This is a great opportunity to experience coaching in real time without any financial risk.

Confidential Self-Assessment Form

Question Scale:
1-Excellent
2-Very Good
3-Needs work
4-Struggle with this
5-Not aware of it's importance

Example: How would you rate your coaching skills? 1 2 3 4 5

Name:
Email:

1. My ability to build and maintain relationships is
   

   1

   2

   3

   4

   5

2. My communication skills are
   

   1

   2

   3

   4

   5

3. My spouse/partner is supportive of my work and I am supportive of his/her work
   

   1

   2

   3

   4

   5

4. When an issue comes up for me, I bring it up right away
   

   1

   2

   3

   4

   5

5. I have a clear vision for my practice
   

   1

   2

   3

   4

   5

6. I truly believe this vision is possible for me
   

   1

   2

   3

   4

   5

7. My actions, thoughts and words match this vision
   

   1

   2

   3

   4

   5

8. I have complete faith in my abilities
   

   1

   2

   3

   4

   5

9. I am earning the money I want to earn
   

   1

   2

   3

   4

   5

10. I save and invest wisely
    

    1

    2

    3

    4

    5

11. I pay my bills on time or early
    

    1

    2

    3

    4

    5

12. I can talk to patients freely and easily about money
    

    1

    2

    3

    4

    5

13. My staff is aware of my vision for the practice
    

    1

    2

    3

    4

    5

14. My staff is highly educated about Chiropractic services
    

    1

    2

    3

    4

    5

15. I am an excellent leader and rarely do I need to hire new people ( Low Employee Turn-over)
    

    1

    2

    3

    4

    5

16. My staff has excellent communication skills
    

    1

    2

    3

    4

    5

17. I eat well and exercise regularly
    

    1

    2

    3

    4

    5

18. I take time off BEFORE I hit burn-out
    

    1

    2

    3

    4

    5

19. I have clear boundaries with others
    

    1

    2

    3

    4

    5

20. I manage my time well
    

    1

    2

    3

    4

    5

21. I use my office space efficiently
    

    1

    2

    3

    4

    5

22. I can easily find files, old x-rays, forms and documents
    

    1

    2

    3

    4

    5

23. I handle tasks that I don't enjoy right away
    

    1

    2

    3

    4

    5

24. My office runs smoothly
    

    1

    2

    3

    4

    5

25. I understand the benefits of coaching
    

    1

    2

    3

    4

    5

26. I am open to learning and I implement new learning
    

    1

    2

    3

    4

    5

27. I am coachable
    

    1

    2

    3

    4

    5