Make Me Better Coaching Intake Form

1

Name

First Name

Last Name

2

Age

3

Date of Birth

Date

4

Gender

Male

Female

Non-Binary

Other

5

Phone Number

6

Email

example@example.com

7

Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

8

Marital Status

Single

Married

Divorced

Widowed

9

Occupation

10

Are you currently taking any medications?

Yes

No

11

If yes, then please indicate the medication name and the purpose below:

12

Do you have any health condition that you would like to share?

Yes

No

13

If yes, then please share them below:

14

What are your personal goals?

15

What are your professional goals?

16

What changes would you like to make in your life right now?

17

What are the things that upset you?

18

What are the things that make you happy?

19

What is your motivation in life?

20

What are you willing to do to achieve your goals?

21

What are your professional strengths and assets?

22

What are your expectations from this coaching relationship?

23

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 coach and the client.

I understand that the coaching services I will be receiving from my Coach are not offered as a substitute for professional mental health care or medical care and are not intended to diagnose, treat or cure any mental health or medical conditions.

25

Would you like to receive product updates, news, and promos?

Yes

No

26

Invoice ID

27

My Products

My Bag

0

30 Minute Session - Pre-ApprovedLimited time training session. Do No Choose unless approved by Coach A prior to booking.
$Free+Edit
Back
Intake Consultation30 minute consultation. If we decide we're a good fit together for your goals, this fee will be applied to the package we decide is best for your goals. Package of no less than 4 sessions required to start for the fee to be applied.
$50.00+Edit
Back
Two SessionsYou will be coached for two sessions.
$180.00+Edit
Back
Four SessionsYou will be coached for four sessions.
$320.00+Edit
Back
Every Week SessionYou will be coached every week. Minimum of 8 Weeks.
$75.00+Edit
Back
8
8
9
10
11
12
13
14
15
16
Number of Weeks

Payment Methods

Credit Card

First Name

Last Name

Cash App

After submitting the form, you will be redirected to the Cash App Pay to complete the payment process.

Google Pay

After submitting the form, you will be redirected to the Google Pay to complete the payment process.