Intake Form

Coaching Intake Form

Please fill out this intake form. Upon completion, you will receive an email to setup a free discovery call.
General
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Client Information

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Why do you seek Coaching?
Do you currently have a coach or mentor?
Referred by:

Employment
Employment: self-employed/contracted, Other:
What is your niche?
What services do you provide?
Who is your target market?
What problems do you solve?
Describe a solution to a problem:

Personal

Consider all areas of life when answering the questions below (Spiritual, Mental, Social, Financial, Familiar, Physical, and Vocational).
Who are you?
What are your strengths?
What are your weaknesses?
What do you want to do?
Who do you want to be?
Where do you want to go?
What are you grateful for in your life?

Mindset

Consider all areas of life when answering the questions below (Spiritual, Mental, Social, Financial, Familiar, Physical, and Vocational).
What are your daily routines?
What do you value the most?
What triggers your mindset?
How do you procrastinate?
If you were a superhero, how would you make the world a better place?

Skillset Assessment
What services do you provide?
What problems do you solve?
Who is your target market?
Describe a solution to the problem:

Personal Development

Consider all areas of life when answering the questions below (Spiritual, Mental, Social, Financial, Familiar, Physical, and Vocational).
What are your goals?
Do you use affirmations?
Do you have a creativity/sacred space?
Do you use a vision board or vision apps?
What educational or motivational resources do you utilize?

Coaching Commitment Statements and Release of Liability
Coaches Commitment

As a coach and trained facilitator, I would like to inform you in advance that I do not treat disease, prescribe drugs, provide therapy, financial advice, or solve legal problems. Therefore, I am not here to take the place of your doctor, therapist, or lawyer.
- I shall endeavor to always serve the best interest of my clients to provide the highest quality service possible. I shall maintain clear and honest communication and keep all communication confidential. I shall remain conscious of the intent and practice good judgment with respect to coaching services provided.
- All information is confidential.
Participants Commitment
- You as the client are always in charge; be ready to process and express your needs.
- Own your emotions and complete homework assignments.
- I Hereby Affirm that I am in good physical condition and do not suffer from any known disability or condition which would prevent or otherwise limit my full participation in this coaching program.
Waiver and Release of Liability

I have been informed and understand the risks and hazards connected with the participation in a Coaching program including, but not limited to:
- Foreseeable and unforeseeable risks of damage and/or physical injury, where I need to be hospitalized. I am voluntarily participating in this activity (Coaching) knowing that the associated physical activity may be hazardous to me and/or my property.
- I voluntarily assume full responsibility for any personal injury that may be sustained by me because of my participation in this Coaching program.
- I am aware and understand that I should carry my own health and property insurance.
In Consideration Of the risk of injury that exists while participating in a coaching program and in my desire to participate in the said activity:
- I Hereby affirm for myself freely and voluntarily release, waive, discharge, and covenant not to sue Wellbeing Center, Inc., and/or officers, consultants, volunteers, from any and all liability, claims, demands, actions, and causes of action whatsoever arising out of or related to any loss, damage, or injury (including, but not limited to, death) that may be sustained by me, or to any property belonging to me, while participating in this program, or while on or upon the premises where the event is being conducted including, but not limited to, any claims arising under recklessness or negligence.
- It is my expressed intent that this waiver and release shall bind all members of my family including, but not limited to, my spouse, my heirs, executors, administrators, assigns, or personal representatives collectively. I hereby further agree that this waiver and release shall be constructed in accordance with the laws of the State of Minnesota.
In signing this waiver and release, I acknowledge and represent that I have read and understood the foregoing and hereby sign it voluntarily as my own free act and deed; no oral representations, statements, or inducements, apart from the foregoing written agreements have been made; and I hereby execute this waiver and release for valuable consideration, intending to be bound by.
- This Waiver and Release of Liability shall remain in effect for the duration of my participation in the Coaching program. During this initial and all subsequent events of participation.
Emergency Contact

First NameLast Name
Relationship to you
Phone Number
Please enter a valid phone number.
Adult Signature for the Coaching Commitment and Waiver

I, the undersigned participant, hereby affirm that I am 18 years of age or older and that I am freely signing this agreement. I certify I have read this agreement, that I fully understand its content and that this release cannot be modified orally. I am aware that this release of liability and contract and I am signing it of my own free will.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Signature

Clear
Date of Signature

MonthDayYear
Date
Parent / Guardian Signature for the Coaching Commitment and Waiver for a Minor

In the event that the participant is under the age of consent (18 years of age), then this release must be signed by a parent or guardian, as follows:
I hereby certify that I am the parent or guardian of the named below, and do hereby give my consent without reservation to the foregoing on behalf of this individual.

First NameLast Name
Parent/Guardian Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship to Minor
Signature

Clear
Date of Signature

MonthDayYear
Date
Should be Empty:

Coaching Intake Form

General

Employment

Personal

Mindset

Skillset Assessment

Personal Development

Coaching Commitment Statements and Release of Liability