Client Intake Form

Name

First NameLast Name

Emergency Contact

Phone Number

Format: (000) 000-0000.

Email

example@example.com

Location (City, State)

Occupation

Are you currently in a situation involving immediate safety concerns?

Marital Status

Length of relationship or marriage

Date of separation

Do you have children? If yes, please share the number and age.

Please provide a summarized description of your divorce or child custody case.

Please describe your ex-partner.

What are your greatest strengths and your biggest weaknesses?

Please describe your ideal outcome in your divorce/custody situation.

Are any of the following high-conflict dynamics present?

Other

Are there active court proceedings?

Are any of the following in place?

Are you currently working with any of the following:

If you are working with an attorney, please share your attorney name if you feel comfortable doing so (optional).

What are you hoping to gain from coaching? Please list your top 3 goals.

Is there anything else you would like me to know?

Please review and acknowledge:

AGREEMENT/REMINDERS:

All information entered in this form will be considered confidential.

The data gathered from this form will only be used as a basis for the type of coaching the client will need.

How did you find out about Sage Rock Coaching?

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