Life Coaching Form

Life Coaching Request Form

The information requested on this form is intended to be helpful to you and Billy Burton in the provision of the best possible service to you. If there is any question that you would prefer not to answer, please feel free to leave blank and we can discuss in our first session.
Name

First Name Last Name
Birth Date

Month Day Year
Gender
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
E-mail
example@example.com
Mobile Number
What are the reason(s) for meeting?
How long has this problem/issue been present?
What solutions have you tried? What were the results?
Did a specific event lead to this request for service? Please describe
How does this problem affect your life? From 0-10 (10 being severe) rate your Personally, Family Life, Socially and Work.
Please describe what you hope to accomplish in our session(s)
Are you currently involved with any community based support groups or professional counseling? If yes, please specify.
Please describe the people in your life that currently play a supportive, influential, or friendship role.
Is there anything else that you would like your coach to know and that you have not written about on this form?
There will be no charge for our sessions but all contributions are appreciated and tax-deductible.

Points to keep in mind

1. Billy Burton is not a licensed mental health provider

2. Billy Burton can not diagnose mental health issues

3. Billy Burton will coach using biblically oriented principles
I acknowledge that the information on this form is accurate to the best of my knowledge, and that I will inform my coach of any changes in my personal circumstances including but not limited to suicidal thoughts and substance use. *

Clear
Should be Empty:

Life Coaching Request Form