Life Schematics Intake Form

Life Coaching Intake Form

Life Audit
Our coaching offers you a fresh perspective on goals you haven’t been able to achieve in life YET! We can reorganize your life to empower you rather than you continue an unsuccessful path. We are an accountability partner, by your side, step by step to ensure you see things through.

An Accountability Guide; someone who’s there for you through life’s most difficult and challenging times. A guide to help you see things differently, refine your approach and achieve your loftiest dreams. We provide unbiased expertise and evaluation that your family and friends may not be able to offer.

www.lifeschematics.com
Please check the items that you believe is affecting you

Alcohol or drug problemsAnger or hostile feelingsAnxiety, nervousness, fearsSadness or DepressionEating or appetite problemsFamily issuesProcrastinationPhysical distressRelationship/marital concernsSexual concernsShynessTraumatic experiencesSocial conflictsSuicidal feelings or behaviorsStressSleep disorderSelf-controlSelf-esteem or confidenceWork or career concerns
Answer each question below with either a 0, 1, 2, 3, or 4

·         0 = Never

·         1 = Almost Never

·         2 = Sometimes

·         3 = Fairly Often

·         4 = Very Often
1. In the last month, how often do you wake up angry?

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2. In the last month, how often have you gone to bed angry?

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3. In the last month, how often have you felt that you were unable to control the important things in your life?

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4. In the last month, how often have you felt nervous and "stressed"?

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5. In the last month, how often have you felt confident in your ability to handle your personal problems?

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6. In the last month, how often have you found out you can't cope with all the things you have to do?

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7. In the last month, how often have you been irritated by others?

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8. In the last month, how often have you felt you are on top of things?

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9. In the last month, how often have you felt angered because of things that were outside of your control?

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10. In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?

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As your coach, do you prefer your daily mindful action via:

Audio MessageText MessagePhone Call
During our face-to-face meetings, do you want a

ListenerCollaboratorLeader/Coach
Would you prefer me to plan your obligations/responsibilities/activies:

DailyWeeklyBi-weekly
Client Name

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
Date Completed

MonthDayYear
Date
LIFE SCHEMATICS

Life Audit
Should be Empty:

Life Coaching Intake Form

LIFE SCHEMATICS