Online Consultation Form

Online Consultation Form

I'm so glad you're taking this exciting step towards your goals! Please take a few minutes to complete this form so I can better understand your aspirations and how I can best support you on your life coaching journey! Once we receive your form, someone will contact you for your free consultation - The Connection Call.
Name*
First and Last
Date of Birth*

MonthDayYear
Gender*

MaleFemale
Marital Status*

SingleMarriedDivorcedWidowed
Occupation*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Email*
example@example.com
Preferred Contact Method
Phone Call, Email or Text
Do you have any health condition(s) that you would like to share?*

YesNo
If yes, please specify below:
Are you currently taking any medications?*

YesNo
If yes, then please indicate the medication name and the purpose below:
What is your reasoning behind wanting to undertake coaching sessions at this stage in your life?*
Have you ever worked with a life coach before?*

YesNo
If yes, please briefly share your experience below:
On a scale of 1 to 10, rate how happy you are currently. Please explain your rating below:*
What makes you happy?*
What is your motivation in life?*
What do you feel are your biggest accomplishments to date? What are you most proud of?*
Please tell me about a time when you had to deal with one of the hardest situations in your life. How did you overcome it?*
What are your personal strengths?*
What are your personal goals?*
What are your professional strengths?*
What are your professional goals?*
What are you willing to do to achieve your personal and professional goals?*
In what way(s) do you learn best? *
Please describe your current self using five (5) different adjectives:*
What three (3) changes would you like to make in your life in the near future?*
On a scale of 1 to 10, how motivated are you to successfully make those changes?*
What "stumbling blocks" do you find often get in your way, preventing you from accomplishing your goals? *
What are your biggest fears?*
What things stress you out the most?*
What are some of your pet peeves or things that upset you?*
How will you know when you're seeing results from the coaching sessions?*
Should you decide to move forward in working together, what do you expect to gain from the coaching sessions?*
Please provide a rough date at which you would like your coaching sessions to begin:*

MonthDayYear
If there is anything else you would like to share that you feel would help the coaching process, please explain below:*
How did you find out about NiQ Life Coaching?*

Social MediaYouTube VideoSearch EngineAdsOther
AGREEMENT:

I understand that all information I entered in this form will be considered strictly confidential.

The information 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.
Once you have read the 'Agreement' section, please sign below:

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