Coaching Intake Form
Becoming You Coaching
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Man
Woman
Nonbinary
Another gender
What are your pronouns?
she/her
he/him
they/them
Other pronouns (please list)
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Marital Status
Single
Married
Divorced
Widowed
What is your current occupation?
How would you describe your current life situation?
What areas of your life feel satisfying or fulfilling right now?
What areas feel challenging, stuck, or unfulfilling?
What motivated you to seek life coaching?
Have you worked with a coach, therapist, or mentor before? (If yes, what worked well or didn't work well?)
On a scale of 1-10, how ready do you feel to make changes in your life? (1 = not ready at all, 10 = completely ready)
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
How do you prefer to be supported? (e.g., accountability, reflective listening, direct feedback, action-oriented tasks)
Is there anything else you'd like me to know before we start working together?
Life Coaching Package
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Five Coaching Session Pack
Five 1:1 coaching sessions with Vicki, online or in person in the Kansas City metro area.
$500.00
$
500.00
How did you find out about our services?
Instagram
LinkedIn
Search Engine
Other
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