EmpowerHer Practice - Coaching Intake Form

Intake Form
Name

First NameLast Name
Date of Birth

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Date
Email
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Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
How did you hear about EmpowerHer Practice?
Business Name (if applicable)
Website/Social Media (if applicable)
Location
What services are you seeking through EmpowerHer Practice?

Other
Specify "Other":
What you would like to achieve through this program? (write "N/A" if not applicable)
What challenges or barriers are current holding you back from achieving these goals?
What is your ideal outcome from this program or service?
What are your top 3 strengths as a person and a professional?
What are your core personal values that guide your decisions and actions?

Other
Please specify "other":
Do you have a niche or ideal client in mind? If yes, who is your ideal client? (age, issues they face, etc)
What motivates you to keep going, even when things get tough?
What type of accountability works best for you?

Other
Other:
Is there anything else you'd like me to know before we begin?
Confidentiality Agreement: EmpowerHer Practice coaching is a supportive and confidential space. By submitting this form, you acknowledge that coaching is not therapy and that results depend on your participation and implementation of strategies discussed.
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