Coaching Intake Form

Coaching Intake Form

Align with Lena
Name

First NameLast Name
Age
Date of Birth

MonthDayYear
Date
Gender Identity

MaleFemaleNon-Binary/Non-conformingTransgenderPrefer not to Respond
Phone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Marital Status

SingleMarriedDivorcedWidowedPrefer not to respond
Current Occupation
Desired Occupation
Are you currently taking any medications?

YesNoPrefer not to respond
If yes, then please indicate the medication name and the purpose below:
Do you have any health condition that you would like to share?

YesNoPrefer not to respond
If yes, then please share them below:
Please list your top 3 personal and professional goals.
What obstacles are hindering your personal and professional development?
What changes would you like to make in your life right now?
If any, what efforts have you made prior to seeking coaching?
What are your professional strengths and assets?
What are your expectations from this coaching relationship?
How can I best support you throughout this relationship?
What is your current level of stress?

1

2

3

4

5

6

7

8

9

10

1 is Low, 10 is High
How would you rate the quality of your life today?

1

2

3

4

5

6

7

8

9

10

1 is Low, 10 is High
How would you rate your self-esteem? (defined as a realistic respect for or favorable impression of one-self; self-respect)

1

2

3

4

5

6

7

8

9

10

1 is Low, 10 is High
How would you rate your self-confidence? (defined as realistic confidence in one's own judgment, ability, or power)

1

2

3

4

5

6

7

8

9

10

1 is Low, 10 is High
Is there anything else you'd like to share with me?
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 life coach and the client.
How did you find out about my services?

Social MediaYouTube VideoSearch EngineAdsWord of MouthOther
Should be Empty: