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Spring-2022 New Client Intake Form
This form is for individuals who are ready to become Clients of THEOO, LCC for Career and/or Life Coaching with Tori Rose. All information supplied here will be housed confidentially and will not be shared with the public. Please complete the fields as openly and honest as possible.
Personal Information
Sharing your personal information helps build the FOUNDATION of your CAREER MAP and strategic plan! Remember, your FUTURE self is waiting!
Name
*
First Name
Last Name
Do you have a preferred name?
Date of birth
Please select a month
January
February
March
April
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Month
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Day
Please select a year
2013
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Year
Cell phone number
*
-
Area Code
Phone Number
Home phone number
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Area Code
Phone Number
Which is you preferred phone?
*
Cell Phone
Home Phone
Personal email
*
Work email
Which is you preferred email?
*
Personal Email
Work Email
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your preferred method of contact?
*
Phone
Email
What is your preferred method for a meeting?
*
Virtual Meeting (Skype, etc)
Phone Call
Other
What are your hobbies / interests?
*
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Employment Status
Your current Employment Status is an important factor in building a strategic for your future and achieving your CAREER goals.
Are you
*
Employed
Retired
Homemaker
Not currently employed, but looking
Name of business (This info may be needed later if a resume or portfolio service is acquired.)
Do you manage others? If yes, # of employees?
*
Place of employment. (This info may be needed later if a resume or portfolio service is acquired.)
Job title
*
Annual gross income
Do you forsee a change in your income in the next 2 years? If so why?
Are you a state employee?
Yes
No
If you are a state employee, what tier are you?
Are you a Fed Gov't employee?
Yes
No
If you are a Fed Gov't employee, what GS or ES are you?
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Family Information
If you have a family, or are planning for one, being in a competitive Career Field and having adequate benefits allows you to be more present and stable for those you love.
Are you
*
Married
Single
Divorced
Widowed
If married, when did you get married?
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
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1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
Year
Is your spouse
Employed
Retired
Business Owner
Homemaker
Not currently employed, but looking
How many children do you have?
*
1st child's age?
2nd child's age?
3rd child's age?
Do you plan on having additional children?
Yes
No
Maybe
If you are currently saving for college: Where are you saving, how much per month and what is the current value?
Any other information you feel we should know related to your family?
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Financial Information
Your financial future is depending on you being in the RIGHT CAREER FIELD and making strategic moves to ensure you reach your goals.
What are your two most important planning issues?
*
Saving for retirement
Saving for college
Protecting my family
Estate planning
Paying off debt
Other
What is the best financial decision / investment you ever made?
What is the worst financial decision / investment you ever made?
If you could pass along 1 financial lesson to your younger self, what would it be?
Do you have a working monthly budget?
*
Yes
No
Please submit a copy of your budget (optional)
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Your Goals, Likes, and Desires
It is time to put you FIRST. The world isn't perfect, BUT you can be intentional about pathing to a Career and ultimately a LIFESTYLE that makes you HAPPY!
Do you have a college degree? If yes, tell me about it. What did you major in? What was your GPA? Why did you choose that area/ field of study?
*
Are you currently working in your field of study? Why or why not?
*
What kind of work or volunteerism would you do if money was not a concern?
*
What did you "want to be" as a child?
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Where do you see yourself in 2 years? 5 years? 10 years? (Please answer at least 2 out of 3 of these yr benchmark questions.)
*
Tell me about a time you invested in yourself. How did it make you feel? Why is investing in yourself important?
*
Have you ever worked with a Life Coach in the past? Please describe your past experience working with an advisor or life coach. What did you like? Where did this person not meet your expectations?
*
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How much are you willing to invest in yourself monthly to access the skills, tools, and resources needed to PIVOT, Progress, and Move yourself forward towards your goals?
*
$0 - $250
$250-$500
$500-$1500+
There's no money amount too great! I am worth the investment!
Are you ready TODAY to hire a Career Coach who can give you the skills and tools to achieve your goals? Why or why not?
*
Any other information you feel we should know?
*
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