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Name: *

E-Mail Address: *

Today's Date:

Phone Number (optional):

Top 3 Visions / Goals: (keywords that remind you of the bigger vision):

Vision / Goal No. 1.

Vision / Goal No. 2.

Vision / Goal No. 3.

Today, I need (check all that apply including those not listed):

Motivation
Encouragement
Support
Resolution
Inspiration
Structure
Accountability
Ideas / Creativity
Feedback
Other (list below)

Other needs (please list):

For the first 15 minutes of our session:

1) How am I today? Anything I need to clear / discuss so I can focus fully on this:

2) Today, I am grateful for:

3) My focused intentions or goals since the last session were:

4) The outcome since our last session (Accomplishments, Wins, or Surprises and also Distractions and Derailments, or Disappointments):

5) Where do I want to focus this session? My intended outcome from this session is (relates to vision/goal from above):

6) Additional updates or thoughts that might be helpful for this session:

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