Client Intake Form

Client Intake Form

Help me get to know you so I can serve you better
Adapted from Gary R. Collins, Used by permission of NavPress (www.navpress.com). Copyright 2013 Christian Coach Institute, LLC All Rights Reserved
Name*

First NameLast Name
Name you would like to be called
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Number*
Please enter a valid phone number.Format: (000) 000-0000.
Work Number
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Occupation*
Employer's Name/Organization Name
Date of Birth*
Marital Status*
Significant Other's Name
Names and Ages of Children

Life Satisfaction Questionnaire
How satisfied are you with different areas of your life? Select a number from 1 to 10 next to each of hte following areas of life.

If you give an item a 1, you are completely dissatisfied with this part of your life. It means, "This part of mylife is entirely unacceptable to me in its current state."

A number 10 means, "I couldn't be happier or more satisfied with this area of life."

Your overall satisfaction will change from day to day, but try to give an overall assessment of where you are at present.

1 -- Completely Dissatisfied 10 -- I could not be happier
Physical Health*
Mental/Emotional*
Career/Employment Satisfaction*
Financial Stability*
Marriage/Romantic Relationships*
Home Life (Immediate Family)*
Extended Family (Relatives, In-laws)*
Friends/Social Life*
Recreation/Relaxation/Leisure*
Lifestyle (Degree of Busyness and Life Balance)*
Personal Life Fulfillment*
Spiritual Health/Life*
Church/Religious Life*
Physical Comfort (Housing, Neighborhood, Possessions, Cars, etc)*
1) Why do you want coaching? Be as specific as possible. Example: "I want to start an exercise program to gain more energy and to lose 30 pounds." *
2) Are you or have you ever been in counseling or therapy? Yes or No, please explain*
3) Describe your spirituality. What is your relationship with God? In what ways do you sense God might be challenging you, nudging you in a different direction, or trying to get your attention?*
4) What are the most important things (good or bad) happening in your life right now?*
5) In what ways would you like your life to be different one year from now? Be specific.*
6) What is getting in the way of your goals?*
7) How might you sabotage yourself as you work toward your goals, or how might you sabotage me as your coach?*
8) List at least three things you procrastinate at -- the things that you've been putting off.*
9) What, if any, are your concerns about coaching?*
10) Rate the level of stress in your life on a scale of 1 to 10. (1=low, 10=high)*
11) What are your primary stressors?*
12) Why did you select me as your coach?*
13) What would you like me to do if you get behind in progress toward your goals?*
14) How do you like to be supported or held accountable?*
15) What else would you like me to know about you?*
Should be Empty:

Client Intake Form

Life Satisfaction Questionnaire