Client Intake Form

Client Intake Form
Name
Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (mobile)

Area CodePhone Number
Phone Number (other)

Area CodePhone Number
Email
example@example.com
Occupation
Employer's Name
Date of Birth

MonthDayYear
Date
Marital Status
Significant Other's Name
Name and Ages of Children
How did you find out about my coaching services? Is there anyone I can thank for referring you to me?

1. Why do you want coaching? Be as specific as possible. Example: "I want to start an exercise program to gain more energy and lose 20 lbs."
2. Are you or have you ever been in counseling or therapy? If yes, please briefly explain.
3. Describe your spirituality. In what ways might you want to include your spiritual life/personal faith in our coaching sessions? (If you'd prefer NOT to include spiritual matters into our coaching session, please feel free to say so!)
4. What are the most important things (good and bad) happening in your life right now?
5. In what ways would you like your life to be different one year from now? Please be specific.
6. What is getting in the way of these goals?
7. How might you sabotage yourself as you work toward your goals, or how might you sabotage me as your coach?
8. List at least three things you procrastinate at--the things you've been putting off.
9. What, if any, are your concerns about coaching?
10. Rate the level of stress in your life on a scale of 1 to 10. (1=low & 10=high)
11. What are your primary stressors?
12. Why did you select me as your coach?
13. What would you like me to do if you get behind in progress toward your goals?
14. How do you like to be supported or held accountable?
15. This is your opportunity to tell me more about you!! What are some of your hobbies and/or favorite pastimes? What makes you laugh? What did you dream of being when you were a child? What are you passionate about? What makes you cringe? (How you respond to this question is entirely up to you. These questions are merely to get you thinking. Please feel free to answer all of them or NONE of them...I just want to get to know a little more about YOU!)
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Client Intake Form

Life Satisfaction Questionnaire