New Client Questionnaire
Personal Information
First Name
Last Name
Preferred Pronouns
Birthday
Address
Address Line 1
Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Email
example@example.com
Preferred Method of Contact
Phone
Text
Email
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Emergency Contact
First Name
Last Name
Email
example@example.com
Phone Number
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Relationship to You
Marital Status
Married
Single
Divorced
Widow
Separated
Domestic Partnership
Non-traditional relationship dynamic (Polygamous, Throuple, Sub/Dom)
Prefer Not to Answer
Do you have Children
Yes
No
If Yes, please list their names and ages.
Does the use of profanity offend you or make you uncomfortable?
Yes
No
Have you ever received therapy/counseling before?
Yes
No
If so, when and what was the outcome?
Have you ever received coaching before?
Yes
No
If so, when and what was the outcome?
What is your spiritual background or practice? How does this influence your inner conversation?
What are three goals you would like to accomplish in the next six weeks, 6 months and 1 year?
When do you feel most inspired? When are you in your element and most creative?
On a scale of 1 to 10, how would you rate your current stress level?
What is your biggest cause of stress?
One a scale of 1 to 10, how would you rate your happiness level? 10 being the happiest, and 1 being miserable.
How do you feel about your life overall.
When was the last time you were proud of yourself? Why?
What does success look like for you?
What are five things that you feel are hindering you from achieving your goals?
Are there any topics that you are sensitive to or are triggering?
Anything that you do not want to talk about or causes a strong reaction.
What do you value most in life right now?
What previous steps have you already taken to achieve your goals? What were the results?
Why do you think you need a life coach? What do you hope to gain from this experience? What are you expectations of me?
What are your expectations of me as a life coach?
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New Client Consultation
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New Client Consultation
30 Minute New Client Consultation. Schedule your first session within a week and have your fee credited towards your session!
$
25.00
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