Client Intake Form

Client Intake Form
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Preferred Contact Method*

PhoneEmailText
Which Program Are You Interested In?*
Which Counseling Package Did You Choose? (Christian Counseling Options Only)
Are you fully ready to commit to taking action, being honest, and doing the work required to create real change in your business?*

Yes, I'm ReadyI'm Almost ReadyI'm Unsure
What do you believe is your responsibility in this coaching process?*
What level of commitment are you prepared to bring to this coaching experience*
What are the main challenges you're facing right now?
What goals would you like to accomplish during our time together?
Have you worked with a coach or counselor before?*

YesNo
If yes, what was your experience like?*
*Christian Counseling Preferences* You understand that our sessions are faith-based and that we offer scripture-integrated guidance?

YesNo
Do you attend a church or have a faith community?
Are there specific spiritual topics you’d like to explore?
Preferred Days/Times for Sessions*

WeekdaysWeekendsMornings (After 10:30)Afternoons
We Meet Via Phone/Video, Does That Work For You??*

YesNo
Is there anything else you’d like me to know?
Agreement & Consent*

I understand this service is not a substitute for medical or psychiatric care.I agree to the terms outlined in the client agreement.I understand that all information shared will remain confidential within legal limits.I am committed to showing up fully to this process.
Signature*

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Date*

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Date
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