Coaching Clinic Intake Form
Please fill out this form so we can understand your goals, challenges, and preferences, ensuring you get the most out of the coaching clinic.
Personal Snapshot
Full Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Marital Status
Please Select
Single
Married
Divorced
Widowed
Email
example@example.com
Employment
Please Select
Employed
Unemployed
Disabled
Retired
Student
Home Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Preferred Method of Contact
E-mail
Home Phone
Cell Phone
Quick Reflection
How would you describe yourself in three words?
What motivates you most at this stage of your life?
What are your top 3 values (non-negotiables)?
Current State of Being
Health & Wellness
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
Family & Relationship
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
Career & Work
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
Personal Growth and Development
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
Spirtuality and Faith
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
Emotional Well-being
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
Leisure & Joy
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
Goals & Objectives
What prompted your interest in joining this coaching clinic?
What is your top priority area for improvement? (e.g., relationships, parenting, career, personal growth, leadership, etc.)
Have you attempted to address this challenge before? If yes, what strategies did you try and what were the results?
How committed are you to taking actionable steps during this coaching clinic?
Not committed
1
2
3
4
Very Committed
5
1 is Not committed, 5 is Very Committed
Challenges & Barriers
What obstacles or challenges are currently preventing you from reaching your goals?
Do you have any fears or concerns about participating in this clinic?
Learning & Participation Preferences
Do you prefer individual coaching, group coaching, or a combination of both?
Individual
Group
Both
How do you best learn?
Visual
Auditory
Kinesthetic
Discussion-based
Hands-on exercises
Are you comfortable sharing openly in group discussions?
Yes
No
Somewhat
Is there any additional information you’d like us to know to make your coaching experience more effective?
*Your signature below indicates that the information you have provided above is truthful.
Date
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Month
-
Day
Year
Date
Signature
Submit
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