Your Information

1. Name: 
2. Date of birth: 
3. Marital status: 
4. Children & Ages: 
5. Email: 
6. Phone number: 
7. Address: 
8. Profession:
9. Website: 

Background and Current State

1. What drew you to this mentoring program?
2. Have you participated in any personal or professional mentoring programs before? If yes, please describe your experience.
3. What is your current level of satisfaction in the following areas of life? (Rate 1–10, with 1 = very dissatisfied and 10 = very satisfied):
   1. Health and well-being
   2. Relationships
   3. Wealth
   4. Professional success
   5. Work
   6. State of mind
   7. State of emotions
   8. Passion for life
   9. Purpose in life
   10. Personal growth
4. What are the main challenges or obstacles you’re currently facing?
5. Are there specific habits, beliefs, or behaviors you want to work on during this program?

About You

1. Do you have a sense of your World View? If you were to complete the sentence “The world is…” with 10 descriptive words what are they: 
2. Do you have a sense of your Personal Philosophy?If you were to complete the sentence “I am…” with 10 descriptive words what are they: 
3. Do you have a sense of the Roles you have in your life? Like “a parent, a child, a caretaker, a businessman, an achiever, a trainer” etc. Pick 3 of your Roles, and choose the 3 most important ones.
4. Do you have a sense of your Goals?
   1. What are your short-term goals? Where do you see yourself in one year?
   2. What are your long-term goals? Where do you see yourself in five years?
5. What are your main motivations when thinking about those goals?
6. What’s holding you back from reaching those goals?
7. What do you feel most excited about in your life at this moment?
8. When you think of your life, what has been your biggest success? What did you do to accomplish it?
9. When you think of your life, what has been your biggest challenge? How did you get past it? Or, if you didn’t, what stopped you?
10. Have you put in work to reach your goals? What worked for you, and what didn’t?

Stress and Emotional Wellbeing

1. What is your current stress level on a scale of 1 to 10? (1 = very low, 10 = very high)
2. Have you experienced significant stress, anxiety, or emotional challenges recently that you’d like to address during these sessions?
3. Do you have any known triggers or areas of sensitivity that we should be mindful of during sessions?

Lifestyle and Habits

1. What is your current level of physical activity? (e.g., sedentary, moderate exercise, very active)
2. Do you have any routines or habits aimed at stress reduction or mindfulness? (e.g., meditation, yoga, journaling)

Preferences

1. When working toward a goal, what motivates you? What hinders your progress?
2. When faced with criticism, how do you handle it?
3. How often do you need to review your progress? How would you like to review it?
4. How can I best support you as your mentor? What do you most need from me?
5. What will make this mentoring experience a success for you?

Additional Information

1. Is there anything else you’d like us to know about you or your expectations for this program?

Consent and Confidentiality

1. Do you consent to participating in Jason’s Personal Mentoring program and understand that this is not a substitute for professional medical or psychological treatment?
2. Do you agree to confidentiality regarding all personal information shared during sessions?
3. Have you read and understood our Terms and Conditions?