1 on 1 Coaching Client Intake Form
Personal Details
Full Name
First Name
Last Name
Age
Gender
Male
Female
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Best time to reach out
Hour Minutes
AM
PM
AM/PM Option
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Current Health Statistics
Weight (kg)
Height (cm)
Appointment
Preferred Day/Days
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Preferred Time
Hour Minutes
AM
PM
AM/PM Option
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Are you currently working with a coach?
Yes
No
Is this the first time you hired a coach or have you been with one before?
Yes
No
What is your purpose in getting a coach?
What are you goals and ambitions in life?
Please fill up the table below:
Rows
Yes
No
Occasional
Remarks/Notes
Difficulty of sleeping
Smoking
Drinking alcohol
Pregnant (Female)
Daily exercise
Surgical History
Drinking soda
Drinking caffeinated products
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Terms and Conditions
I confirmed that all information in this form is accurate and try to the best of my knowledge.
I confirmed that I have read the contents of this form including these terms and agreement.
I understand that this clinic or health facility will protect all the information in this form and will keep it confidential.
I understand that this clinic/facility accepts cash, check, and credit cards for payment methods.
I understand that this procedure is not considered professional advice. It is recommended to seek professional advice from professionals like lawyers, physicians, spiritual, and financial.
I confirmed that I have the right to terminate this care at any time.
I released this clinic or facility from any liabilities like injuries, accidents, or damage that might happen during the procedure.
I understand that this procedure doesn't guarantee specific results or outcomes.
Signature
Date Signed
-
Month
-
Day
Year
Date
Submit
Submit
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