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Self Assessment Form

Coaching Assessment

THIS INFORMATION WILL BE KEPT PRIVATE AND SECURE. IT WILL BE USED TO HELP US DETERMINE IF THE DATEWISE COACHING IS THE RIGHT FIT FOR YOU. WE WILL DISCUSS THIS IN MORE DETAIL IN OUR INITIAL 45-MINUTE PHONE CONVERSATION. THANK YOU!

Note: The term “caregiver” is used instead of parent, because you might have been raised by someone other than a parent (an aunt, grandmother, or older sibling, etc.).

(check all that apply)


3. Describe how your caregivers responded in the following scenarios:
(check all that apply)


(check all that apply)


(check all that apply)


12. On a scale of 1 to 10, with 10 being the highest, how would you rate yourself on the following?