Client Intake Form
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Best Time To Call:
Is it okay to leave a message?
Yes
No
Gender
Male
Female
Age
Date of Birth:
Number of Childern
Ages of Children
Education:
High School
Some College
BA/BS
MA/MS
PhD
Occupation/Company Name
Position Title:
How long at this employment?
Are you satisfied with your current job? If not, kindly share with me briefly what changes you would like to make in your professional life.
Emergency Contact Name:
Relationship:
Phone Number:
Your Goals: What 3 goals would you like to accomplish within the next 3 to 6 months?
What is 1 major goal would you like to accomplish within thenext 12 months?
What are your greatest challenges?
What do you expect to achieve as a result of hiring me as your coach?
Do you have a Higher Purpose? If so, please briefly describe.
If you were guaranteed success, what endeavor would youstrive to accomplish?
Rate your quality of life. On a scale of 1 to 5 (5 Best quailty of life)
Bad quality of life
1
2
3
4
Best quality of life
5
1 is Bad quality of life, 5 is Best quality of life
Rate your Health. On a scale of 1 to 5 (5 Great health)
Bad Health
1
2
3
4
Great Health
5
1 is Bad Health, 5 is Great Health
Rate your stress level. | On a scale of 1 to 5 (5 as the High Stress Level)
Low Stress Level
1
2
3
4
High Stress Level
5
1 is Low Stress Level , 5 is High Stress Level
Here are a few ways to coach clients. Which one's appeal to you?
Working through Self-Improvement Programs together.
Support, Encouragement, and Validation
Accountability, Checking up on goals
Suggestion or designing action steps
Brainstorming Strategies Together
Please verify that you are human
*
Submit
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