Conscious Wellness Client Intake Form

Conscious Wellness Group — Heather Cromartie | Life Coach

Complete this questionnaire to help us personalize your coaching experience and understand your goals and challenges.
Client Intake Questionnaire
Thank you for choosing to work with Heather Cromartie | Life Coach. This questionnaire is designed to help us gain a clear understanding of your current situation, goals, strengths, challenges, and vision for your future. Your responses will help create a coaching experience that is personalized, focused, and aligned with what matters most to you.
SECTION 1: PERSONAL INFORMATION
Full Name
Preferred Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Occupation
Relationship Status
City and State
Emergency Contact Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
How did you hear about Heather Cromartie | Life Coach?
SECTION 2: CURRENT LIFE ASSESSMENT
Instructions

Please rate your current level of satisfaction in each area of your life using a scale of 1-10.

1= Very Dissatisfied

5=Neutral

10=Extremely Satisfied

There are no right or wrong answers. Please answer honestly based on how you feel today. Your responses will help us identify the areas that may benefit most from coaching.
Health & Wellness
Career / Work
Relationships
Personal Growth
Financial Confidence
Environment
Time Management
Overall Life Satisfaction
What area received your lowest score and why?
What area received your highest score and why?
SECTION 3: VISION & FUTURE GOALS
What are the top three goals you would like to achieve through coaching?
If coaching were extremely successful, what would be different in your life 12 months from now?
Describe your ideal life three years from today.
What would make you feel proud of yourself one year from now?
What does success mean to you personally?
What kind of person do you want to become?
What changes would have the greatest positive impact on your life?
If there were no limitations, what would you create for yourself?
SECTION 4: CHALLENGES & OBSTACLES
What challenges are currently creating the most frustration in your life?
What goals have you struggled to achieve on your own?
What habits or behaviors are preventing you from reaching your goals?
What distractions most often pull you away from your priorities?
What obstacles repeatedly show up in your life?
What have you already tried to create change?
What worked?
What did not work?
Are there any recurring patterns you would like to break?
What do you believe is the biggest thing standing between you and the life you want?
SECTION 5: VALUES & PRIORITIES
Select your five most important values
Why are those values important to you?
What matters most to you right now?
What are your top three priorities for the next six months?
Where is there a gap between what you value and how you currently spend your time?
SECTION 6: HABITS & LIFESTYLE
Describe a typical weekday.
Describe a typical weekend.
What habits are helping you move forward?
What habits are holding you back?
How would you rate your energy level?
How would you rate your consistency?
How would you rate your self-discipline?
How often do you intentionally engage in self-care?
What areas of your routine need the most improvement?
What one habit would create the biggest positive impact in your life?
SECTION 7: READINESS & COMMITMENT
Why is now the right time for change?
What happens if nothing changes over the next year?
How motivated are you to make meaningful changes?
How committed are you to taking action between coaching sessions?
How willing are you to step outside your comfort zone?
How open are you to honest feedback?
How willing are you to be accountable for your progress?
What might prevent you from fully committing to this process?
What strengths will help you succeed?
SECTION 8: COACHING EXPECTATIONS
Why did you decide to hire a coach at this point in your life?
What type of support would be most valuable to you?
What are you hoping to gain from coaching?
How do you learn best?
What qualities are most important in a coach?
What does a successful coaching relationship look like to you?
Is there anything you want your coach to know about how you prefer to receive feedback?
SECTION 9: FINAL REFLECTION
What is one truth about your life that you know you need to face?
What have you been tolerating for too long?
What are you no longer willing to accept?
What would become possible if you fully trusted yourself?
What is one decision you know you need to make?
What is one action you have been avoiding?
What kind of legacy do you want to create?
What would you like your future self to thank you for?
If we were celebrating your success one year from now, what would we be celebrating?
Is there anything else you would like Heather to know before your first coaching session?
FINAL SECTION
I understand that life coaching is not therapy, counseling, mental health treatment, medical advice, legal advice, or financial advice. Coaching is a collaborative process focused on personal growth, accountability, goal achievement, and lifestyle improvement.
I certify that the information I have provided is accurate and complete to the best of my knowledge.
Electronic Signature
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Conscious Wellness Group — Heather Cromartie | Life Coach

SECTION 1: PERSONAL INFORMATION

SECTION 2: CURRENT LIFE ASSESSMENT

SECTION 3: VISION & FUTURE GOALS

SECTION 4: CHALLENGES & OBSTACLES

SECTION 5: VALUES & PRIORITIES

SECTION 6: HABITS & LIFESTYLE

SECTION 7: READINESS & COMMITMENT

SECTION 8: COACHING EXPECTATIONS

SECTION 9: FINAL REFLECTION

FINAL SECTION