Life Coach Intake Form

Name

First NameLast Name

Age

Date of Birth

Date

Gender

Phone Number

Format: (000) 000-0000.

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Marital Status

Occupation

Are you currently taking any medications?

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

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

If yes, then please share them below:

What are your personal goals?

What are your professional goals?

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

What are the things that upset you?

What are the things that makes you happy?

What is your motivation in life?

What are you willing to do to achieve your goals?

What are your professional strengths and assets?

What are your expectations from this coaching relationship?

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.

Payment Method

How did you find out about our services?

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

My Products

Two Sessions

You will be coached for two sessions.

$100.00

Six Sessions

You will be coached for five sessions. Weekly or Biweekly (recommend).

$200.00

Refuel Sessions

You will be coached as needed. Flat rate of $80 for first hour per session and $5 for every hour over.

$80.00 Number of Weeks

Non-refundable deposit

$50.00

Total

Payment Methods

Credit Card

Cash App Pay