Lawrence E. Adjah, MBA, M.Ed, MDiv - Coaching Intake Form

Lawrence E. Adjah, MBA, M.Ed, MDiv - Coaching Intake Form
What type of coaching are you seeking at this time?*
If you selected -Life Coaching- above, what level of coaching are you seeking?
Your Full Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Birth Date*

MonthDayYear
Date
Life Stage*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Where are you seeking the most guidance?*
In a few sentences, tell me: If we were to work together, what specific outcome or transformation would you be seeking to achieve?
How would you measurably define success?
Spiritual Intake
Describe Where You Sense You Are in Your Faith Journey? (Best Description)*
Have You Ever Been Baptized?*
How often do you talk to God?*

1

2

3

4

5

6

7

8

9

10

1 is Rarely, if Ever, 10 is Consistently throughout the day, everyday
Have you ever shared your "testimony" or "God story" with anyone? (e.g. when and why you recognized your need for God, what drew you and lead you to make a lifelong commitment)*
Are You Currently Part of a Faith Community? (for teaching, prayer, accountability & community)*
Describe Your Level of Understanding of the Bible*
Describe Where You Sense You Are Around Biblical Generosity & Stewardship*
Are You *Currently* in Counseling/Therapy?*
Are you aware of your (spiritual) gifts?*
Physical Intake

Health & Lifestyle*

	Yes	No
Have you had a physical within the last 12 months?
Do you have a gym membership?
Do you take any prescription medication for any current health condition?
Are you using any additional vitamin or supplements?
Do you drink alcohol?

How often do you currently lift per week? (on average)*

3 x per week< 3 x per week> 3 x per weekNever
How often do you currently run / do cardio activity per week? (on average)*

3 x per week< 3 x per week> 3 x per weekNever
How healthy do you eat? (Your Nutrition)*

1

2

3

4

5

6

7

8

9

10

1 is Not healthy at all, 10 is Extremely clean and healthy
Relational Intake
Are there any interpersonal relationship challenges with a significant other, family members, friends and/or colleagues that you are actively looking to work through in this season*
How often do you socialize with friends in person?*
How many close friendships do you currently have and actively maintain?*
How many older personal mentors do you currently have and actively keep in touch with?*
How many friends do you currently have who will show up for you "No Questions Asked?"*
If you call them and ask them to show, they will show.
How many groups are you currently a part of (who account for you if you do not show) who meet in-person or virtually at least bi-weekly?*
If you call them and ask them to show, they will show.
Your Current Occupation*
Commitment
Why is *right now* the right time for coaching for you?
Are you willing to commit to:

- Investing into your growth and transformation

- Showing up on time for sessions

- Being honest

- Being open to biblical wisdom and strategic guidance

- Completing any assigned work between sessions

- Understanding this is a Spirit-led process
Yes, I am willingNo, I am not ready yet
How Did You Hear About My Services?*
Date

MonthDayYear
Date
Client Signature

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Lawrence E. Adjah, MBA, M.Ed, MDiv - Coaching Intake Form

Spiritual Intake

Physical Intake

Relational Intake

Commitment