Client Intake Form

Living in the Light

Client Intake Form
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Email
example@example.com
Mobile Number

Area CodePhone Number
Home Number

Area CodePhone Number
Occupation
Employer
Marital Status
Significant Other's Name

First NameLast Name
Names and Ages of Children:
LIFE SATISFACTION QUESTIONAIRE

How satisfied are you with different areas of your life? Select a number from 1 to 10 next to each of the following areas of life. If you give an item a 1, you are completely dissatisfied with this part of your life. It means, “This part of my life is entirely unacceptable to me in its current state.” A number 10 means, “I couldn’t be happier or more satisfied with this area of life.” Your overall satisfaction will change from day to day, but try to give an overall assessment of where you are at present.

Physical Health

	1	2	3	4	5	6	7	8	9	10

1 is Completely Dissatisfied, 10 is Could not be Happier

Mental/Emotional Health

	1	2	3	4	5	6	7	8	9	10

1 is Completely Dissatisfied, 10 is Could not be Happier

Career/Employment Health

	1	2	3	4	5	6	7	8	9	10

1 is Completely Dissatisfied, 10 is Could not be Happier

Financial Stability

	1	2	3	4	5	6	7	8	9	10

1 is Completely Dissatisfied, 10 is Could not be Happier

Marriage/Romantic Relationships

	1	2	3	4	5	6	7	8	9	10

1 is Completely Dissatisfied, 10 is Could not be Happier

Home Life (Immediate Family)

	1	2	3	4	5	6	7	8	9	10

1 is Completely Dissatisfied, 10 is Could not be Happier

Extended Family (Relatives, In-laws)

	1	2	3	4	5	6	7	8	9	10

1 is Completely Dissatisfied, 10 is Could not be Happier

Friends/Social Life

	1	2	3	4	5	6	7	8	9	10

1 is Completely Dissatisfied, 10 is Could not be Happier

Recreation/Relaxation/Leisure

	1	2	3	4	5	6	7	8	9	10

1 is Completely Dissatisfied, 10 is Could not be Happier

Lifestyle (Degree of busyness and life balance)

	1	2	3	4	5	6	7	8	9	10

1 is Completely Dissatisfied, 10 is Could not be Happier

Personal Life Fulfillment

	1	2	3	4	5	6	7	8	9	10

1 is Completely Dissatisfied, 10 is Could not be Happier

Spiritual Health/Life

	1	2	3	4	5	6	7	8	9	10

1 is Completely Dissatisfied, 10 is Could not be Happier

Church/Religious Life

	1	2	3	4	5	6	7	8	9	10

1 is Completely Dissatisfied, 10 is Could not be Happier

Physical Comfort (Housing, Neighborhood, Possessions, Cars, etc.)

	1	2	3	4	5	6	7	8	9	10

1 is Completely Dissatisfied, 10 is Could not be Happier

GETTING TO KNOW YOU
Why do you want coaching? Be as specific as possible. Example: “I want to start an exercise program to gain more energy and to lose 30 pounds.”
Are you or have you ever been in counseling or therapy?

YesNo
If yes, please explain.
Describe your spirituality. What is your relationship with God? In what ways do you sense God might be challenging you, nudging you in a different direction, or trying to get your attention.
What are the most important things (good and bad) happening in your life right now?
In what ways would you like your life to be different one year from now? Be specific.
What is getting in the way of these goals?
How might you sabotage yourself as you work toward your goals, or how might you sabotage me as your coach?
List at least three things you procrastinate at -- the things that you’ve been putting off.
What, if any, are your concerns about coaching?
Rate the level of stress in your life on a scale of 1 to 10. (1=low and 10=high)
What are your primary stressors?
How did you select me as your coach?
What would you like me to do if you get behind in progress toward your goals?
How do you like to be supported or held accountable?
What else would you like me to know about you?
Should be Empty: