Its Your Time Intake Form

It's Your Time Coaching Intake Form

Name

Date of Birth

Date

Gender

Phone Number

Email

example@example.com

Address

Marital Status

Occupation

Are you currently taking any medications

Do you have any health conditions that you would like to share

Do you exercise often If yes what type and how often

What are the things that upset you

What are the things that make you happy

How would you rate your current physical health? (Poor, Fair, Good, Excellent) How would you rate your current mental health? (Poor, Fair, Good, Excellent) Coaching Goals

What prompted you to seek coaching

What are your primary goals for coaching

What are your personal goals

What are your professional goals

What changes would you like to make in your life right now

What is your motivation in life

What are you willing to do to achieve your goals

What are your professional strengths and assets

Current Challenges

What do you see as your biggest challenge right now

Are there any obstacles that you feel are holding you back

How have you tried to address these challenges in the past

What do you believe is preventing you from achieving your goals

How would you describe your selfconfidence

How do you handle stress and pressure

What are your strengths

What are your weaknesses

How do you make important decisions

What are your core values

What motivates you

What are your biggest fears

What does success mean to you

Describe a typical day in your life

What are your daily routines and habits

How do you spend your free time

Do you have any habits you want to change

How much time are you willing to commit to coaching

Are you open to homework or exercises between sessions

Have you worked with a coach before If yes what was the experience like

What are your expectations from our coaching relationship

What would you like to achieve by the end of our coaching sessions

What is your timeline for achieving these goals

Is there anything else you would like me to know before we begin

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

The data 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 coach and the

One Session $80

Five Sessions $375

12 Sessions $900

Weekly Sessions $60 ( Must Subscribe to automatic payments for 12 months.) You will be coached every week.

Cancelled: No Show or sessions that cannot be rescheduled sessions are NON-REFUNDABLE due to the

preparation work to plan the tailored sessions. Requests to reschedule should be made no later than within 48 hours of the appointment. (Note: Rescheduling is not guaranteed depending upon the coach's availability

What Session are you signing up for?

How did you find out about our services?

By Signing Below you agree to the terms of the session that you have signed up for.