Life Coaching Intake

“GETTING TO KNOW YOU
Coaching is more effective and efficient if you can give me some information about yourself at the beginning. This is confidential information and you are free to not answer any of the questions. I encourage you to be open and share the information in order to get the most from our coaching relationship.
Name
Name you like to be called
Address
Phone: (Home)
(Work)
Phone: (Mobile)
(Fax)
Email
example@example.com
Occupation
Employer’s name
Date of birth

MonthDayYear
Date
Marital status
Significant Other’s Name

Names and Ages of Children:

	Name:	Age:	Name:	Age:

Life Satisfaction Questionnaire
Physical Health
Career/Employment Satisfaction
Financial Stability
Marriage/Romantic Relationships
Home Life (Immediate Family)
Friends/Social Life
Recreation/Relaxation/Leisure
Lifestyle (Degree of Busyness and Life Balance)
Personal Life Fulfillment
Spiritual Health/Life
Church/Religious Life
Physical Comfort Housing, Neighborhood, Possessions, Cars, etc
Are you or have you ever been in counseling or therapy? 2.

YesNo
3. 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.
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? Be specific.
5.In what ways would you like your life to be different one year from now? 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?
9.What, if any, are your concerns about coaching?
Coaching Disclaimers Below:
Confidentiality-

All information obtained in the life coaching sessions is confidential unless there is compelling professional reasons for its disclosure. Your coach will disclose confidential information if necessary to prevent harm to self or to others.
Life coaching is for women only, and no minors will be treated in this coaching.

Life coaching is Christian based and uses principles and guidelines throughout the Bible. Some sessions may include deliverance ministry and/or words of knowledge given by the Holy Spirit.
Internet and electronic communications-

Services are provided via through the internet using video conferencing, email, chat, and phone through Whats App. You understand that there are times that services cannot be rendered do to internet connectivity issues, and your coach will reschedule your session as soon as possible without charge. You also understand that your coach will do her best to always provide and safe and secure connection, but with that said there are no guarantees of this.
All coaching services and communications, delivered by your coach, Stephanie Reck are meant to help you identify the challenges in your life that are hindering you or keeping you stuck.

This agreement is for my coaching services not counseling. I will not offer a mental health diagnoses, or treat mental health issues. Referrals to mental health counselors will be given if needed.
Appointment scheduling and cancelation polices-

You can book online at my website for coaching @ www.stephaniereck.com or you can send me an email to info@stephaniereck.com to inquire about Google Meet, Email, and Phone coaching. In order to cancel your appointment, you are asked to notify 24 hours in advance, otherwise you will be charged in full. If your coach has to cancel, she will do her best to give 24 hours notice and to reschedule as soon as possible with you.
I hereby release, waive, acquit, and forever discharge my coach, Stephanie Reck and her business, Stephanie Reck, Coaching & Consultation Services, LLC from:

every claim, suit action, demand, or right to compensation damages I may have or that I may have arising out of acts of omissions by my coach or myself as a result of advice given by my coach or otherwise resulting from this coaching relationship. This agreement shall bind my heirs, executors, personal representatives, successors, assigns, and agents. Your electronic signature indicates that you have read through this intake and waiver and understand its contents.
Signature

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Payment information/insurance-

Services are to be paid in full before the session. Payment is accepted through all major credit cards, PayPal, Venmo, and CashApp. Because life coaching is not medical treatment, typically insurance will not cover the expense. However, you will find my coaching very affordable.
Date

MonthDayYear
Date
You can also pay for a life coaching session here and coach will email you details for your session. If you have paid via my website, ignore this section.
prevnext( X )
LIFE COACHING Session (45-60 minutes)
$75.00 Quantity



First ConsultationFirst (30) minute consultation with me is free.
$ Free Quantity



Email coaching(3) emails from client and (3) reply emails from coach. Emails are not to be any longer than 500 words.
$25.00 Quantity



Total

$0.00

“GETTING TO KNOW YOU

Coaching Disclaimers Below:

Confidentiality-

Life coaching is for women only, and no minors will be treated in this coaching.

Internet and electronic communications-

All coaching services and communications, delivered by your coach, Stephanie Reck are meant to help you identify the challenges in your life that are hindering you or keeping you stuck.

Appointment scheduling and cancelation polices-

I hereby release, waive, acquit, and forever discharge my coach, Stephanie Reck and her business, Stephanie Reck, Coaching & Consultation Services, LLC from:

Payment information/insurance-