BYB Coaching Intake Form

1

Name

First Name

Last Name

2

Email

example@example.com

3

Phone Number

Please enter a valid phone number.

4

Relationship Status

5

Children's names and ages (if applicable):

6

Occupation

7

Goals of Pleasure & Discovery Coaching

9

List 3 adjectives that describe you at your best

10

List 3 that describe you at your worst

11

What do you think has been holding you back from achieving your goals? (Include any obstacles, experiences, fears, concerns, people, etc.)

12

What are the things that stress you out the most?

13

What motivates you the best?

14

Who did you learn about relationships and love from? What did they tell you?

15

Have you ever worked with a coach, counselor or therapist before? If yes, what worked well for you and what did not work?

16

How would you describe the best relationship that you've had?

17

How would you describe the most difficult relationship that you've had? How would you describe a perfect relationship for you?

18

Are you aware that Pleasure and or Relationship Coaching is not sex therapy, psychiatry, or psychology?

YESNO

19

SignatureI affirm that all information provided is accurate. I unserstand that payment is due prior to services being rendered.

Clear

20

Receipt of Privacy Policy and Terms & ConditionsBoth documents linked in verbiage above. My signature confirms I have received both documents and agree to proceed with service as outlined.

Clear

21

Today's Date

Date