PRIMAL LIFE coaching & mentoring
Use this intake form to share your contact info, goals, life context, and health background so we can understand fit and readiness. This isn’t a substitute for medical, psychological, or emergency care.
Contact Information
Full Name
*
First Name
Last Name
Preferred Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Location / Time Zone
*
Preferred Contact Method
*
Email
Phone
Text/SMS
Other
Birthday
Gender
Coaching & Mentoring Goals
What drew you to Primal Life coaching/mentoring?
*
What are your top 1–3 goals right now?
*
What areas of life feel most important to work on?
*
Life direction / purpose
Health / wellness
Embodiment / fitness
Emotional resilience / regulation
Relationships / family
Nature connection / tracking
Skills / primal living
Leadership / service
Martial art / protection
Learning / training
Mentoring / teaching
Rites of passage / transition
Philosophy / worldview
Spiritual practice / direction
Professional / vocational
Other
Current Life Context
Briefly describe your current work/life situation.
*
Are you experiencing any major transitions or stressors?
What support systems do you currently have in place?
What has helped you in the past?
Health & Safety History
Are there any physical health considerations, injuries, or movement limitations we should know about?
Are you currently taking any medications or treatments relevant to coaching?
Is there anything in your mental or emotional health history relevant to participation?
Are there any trauma histories or triggers your coach should be aware of?
Do you have any concerns regarding substance use?
Are you currently under the care of a physician or mental health professional?
Yes
No
Emergency Contact Name
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Relationship
*
Practice Readiness
How would you rate your current sleep quality?
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
How would you rate your current nutrition habits?
Needs improvement
1
2
3
4
Optimal
5
1 is Needs improvement, 5 is Optimal
How would you rate your current movement/physical activity?
Low
1
2
3
4
High
5
1 is Low, 5 is High
How much time do you spend in nature?
Rarely
1
2
3
4
Daily
5
1 is Rarely, 5 is Daily
How would you rate your spiritual or contemplative practice?
Not present
1
2
3
4
Consistent
5
1 is Not present, 5 is Consistent
How would you rate your current stress level?
Low
1
2
3
4
High
5
1 is Low, 5 is High
Which coaching style do you prefer?
Gentle/supportive
Structured/accountability
Deep inquiry/Socratic
Practical skills instruction
Spiritual/contemplative
Direct challenge/motivation
Dialogical/philosophical
Coyote/Mystery
Other
Consent & Boundaries
Final Reflection
What would make this work meaningful or successful for you?
Is there anything else I should know before we meet?
Agreements
I understand that coaching and mentoring are educational and developmental services, not psychotherapy, counseling, medical treatment, or crisis intervention. I remain responsible for my own decisions and actions, and I agree to participate honestly and respectfully. I agree to communicate honestly about any health concerns that could affect my participation and will inform my coach of any significant changes during our work together.
I understand and agree.
I have read the terms of service and agree with its terms.
Yes
No
I have read the coaching agreement and agree with its terms.
Yes
No
I have read the waiver and agree with its terms.
Yes
No
Signature
Submit
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