Coaching Intake Form

Legacy Lifestyles

New Coaching Client Intake Form
Name*

First NameLast Name
Phone Number*
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Place of Birth*
Facebook Page (personal)?
Other primary social media site?
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you currently seeing a therapist?*

YesNo
If so, does your therapist know you're seeking coaching?

YesNo
Any health concerns?
Religious background? Are you active? *
Marital status? Children/pets?*
What is the most significant thing going on in your life right now?
What do you do?*

StudentHomemakerCareer WomanEntrepreneurOther
List any of your websites here.
Coaching Terms & Conditions:

1. Coachig fees are paid in advance, and fees are non-refundable.

2. Fees are $150 per half-hour phone session unless other arrangements made.

2. The client calls the coach at an agreed upon date and time.

3. If client calls late, the session still ends at it's scheduled ending time.

4. If client does not call, client agrees to pay for the time slot.

5. If client cancels with 24 hours advance notice, session is rescheduled.
Do you agree to the above coaching terms and conditions.*

YesNo
Should be Empty: