1:1 Recovery Coaching Intake Form

1:1 Recovery Coaching Intake Form

Hi there! Thank you for reaching out with your interest in working together! Please take a few moments to complete this application so that I can learn a bit about you and your journey. Upon submission, please allow up to 1 week for me to review and contact you.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Preferred Pronouns*
Where are you currently at on your sobriety journey?:*
Example: I am currently sober, I have tried sobriety in the past, I am interested in trying sobriety, etc
What has led you to seek out a coach?*
What are your goals and/or what changes would you like to make in your life right now?*
Have you ever worked with a therapist or coach?*
What are your expectations from this coaching relationship?*
What do you currently do for work?
You can skip this if you'd like
Phone Number*
Email*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
AGREEMENT/REMINDERS:I understand that all information I entered in this form will be considered strictly confidential.The data gathered from this form will only be used as a basis for the type of coaching the client will need.I understand that in order to be successful, it is vital to follow the plan agreed by both the life coach and the client.
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