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TEC Mental Performance Questionnaire
Date
MM slash DD slash YYYY
Name
First
Last
Email
Phone
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
What types of physical activities do you participate in?
What are the reasons you engage in physical activity?
Is your happiness dependent on your performance? Ie: Do you feel like if you performed well you are happy, and if you don't, you are unhappy?
Is there a coach or athlete that you look up to as a role model and why?
What are your goals/expectations as it relates to your athletic pursuits?
If you carry on as you are, with no mental training, where do you think your performance will be in 3 years? How does this match up with how you would like to perform and train?
Describe your ideal vision of what it means to be performing as the best version of yourself?
What strengths do you posses that make you a capable athlete?
In general, what do you think limits your performance the most?
Have you worked with a mental performance coach, therapist, or life coach before?
Why do you want to work with a mental performance coach?
Agreement to use Thomas Endurance Coaching Inc. Services and Waive Liability
(Required)
I have read, understand, and agree to the waiver.
Coaching is a collaborative process with an ongoing relationship between the Client and Coach. The coaching experience supports the Client in establishing new behaviors. The coaching relationship is strengths-based, forward-looking, and collaborative. The coaching agenda is developed and implemented in partnership between the Client and Coach. The role of the Coach is to help the Client progress toward achieving a goal. The Client and Coach agree to engage fully in the coaching experience. The Client recognizes that coaching is not therapy, counseling, or consulting. Should a serious concern arise beyond the scope of practice, the Coach will recommend that the Client see a specialist. Finally, in consideration of choosing to engage in this program, I agree to assume the risks, and further agree to hold harmless Thomas Endurance Coaching Inc. from any and all claims, suits, losses, and/or related causes of actions and damages, including, but not limited to, such claims that may result from my injury or death, accidental or otherwise, during or arising in any way from, these services.
Confidentiality:
The Coach agrees to keep all conversations and information with the Client private and confidential, as allowable by law. No personal information will be shared with anyone without the Client’s express permission. Exceptions may be made if there is an imminent threat of serious injury to oneself or someone else.
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