Coaching Intake Form
General Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Name:
*
Emergency Contact Phone:
*
Please enter a valid phone number.
Format: (000) 000-0000.
What is their relationship to you?
*
How may Sara contact you?
*
Phone
Text
Email
Postal Mail
Gender Identity:
Sexual Orientation:
Marital Status
Single
Partnered
Married
Divorced
Other
Company Name or Field of Employment/Education
Job Title
Do you have children?
What concerns/issues led you to seek coaching?
*
Do you have any specific goals with regard to coaching?
*
Do you have any fears/hesitations related to receiving coaching?
*
Medical Info
Have you experienced any significant medical issues (ie accidents, surgeries, illness)? Please describe:
Are you currently taking any medications?
yes
no
If yes, what are they for?
Have you ever attempted suicide? If so, when?
*
Are you currently experiencing suicidal thoughts?
*
yes
no
Do you smoke? How many years have you smoked?
Do you drink alcohol? If so, how often and how many years have you been drinking?
Do you use any illegal/recreational drugs (ie marijuana, cocaine, meth)? If yes, please describe your use.
Family History
How would you describe your childhood? Provide as much detail as you'd like
Describe the current, significant relationships in your life (ie spouse, partner, close friends, etc)
Describe your current/immediate family
Additional Information
Please describe your spiritual identity/orientation
What are your interests or hobbies and how often are you able to pursue them?
Describe your strengths
Describe your weaknesses
Additional Comments
Submit
Should be Empty: