Client Intake Form_Free

NEW CLIENT INTAKE FORM: Starting College Strong!
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
Fax Number

Area CodePhone Number
College
Major
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. A number 10 means "Completely Satisfied" A number 1 means "Dissatisfied". Try to give an overall assessment of where you are at present. Skip any question you do not feel comfortable answering.

FAMILY

	1	2	3	4	5	6	7	8	9	10

1 is Dissatisfied, 10 is Completely Satisfied

SCHOOL

	1	2	3	4	5	6	7	8	9	10

1 is Dissatisfied, 10 is Completely Satisfied

ACADEMICS

	1	2	3	4	5	6	7	8	9	10

1 is Dissatisfied, 10 is Completely Satisfied

SOCIAL

	1	2	3	4	5	6	7	8	9	10

1 is Dissatisfied, 10 is Completely Satisfied

FRIENDS/COLLEAGUES

	1	2	3	4	5	6	7	8	9	10

1 is Dissatisfied, 10 is Completely Satisfied

WORK

	1	2	3	4	5	6	7	8	9	10

1 is Dissatisfied, 10 is Completely Satisfied

HEALTH/FITNESS

	1	2	3	4	5	6	7	8	9	10

1 is Dissatisfied, 10 is Completely Satisfied

SELF IMAGE

	1	2	3	4	5	6	7	8	9	10

1 is Dissatisfied, 10 is Completely Satisfied

SLEEP

	1	2	3	4	5	6	7	8	9	10

1 is Dissatisfied, 10 is Completely Satisfied

VOLUNTEER WORK

	1	2	3	4	5	6	7	8	9	10

1 is Dissatisfied, 10 is Completely Satisfied

FAITH

	1	2	3	4	5	6	7	8	9	10

1 is Dissatisfied, 10 is Completely Satisfied

PERSONAL TIME

	1	2	3	4	5	6	7	8	9	10

1 is Dissatisfied, 10 is Completely Satisfied

BUDGET/FINANCES

	1	2	3	4	5	6	7	8	9	10

1 is Dissatisfied, 10 is Completely Satisfied

GETTING TO KNOW YOU
Tell me a little about yourself so I can help you reach your goals! What do you hope to gain from coaching? Think about your vision and how coaching might help you. Examples: “I want more structure and balance in my life." "I want to prepare now to be successful in my classes." or "I want to establish a routine and schedule to stay on track." What is your ideal goal?
What were your favorite classes in High School? Where did you succeed?
What are your favorite hobbies, movies, music & activities?
What are the most important things (good and bad) happening in your life right now?
Are you or have you ever been in counseling or therapy?

YesNo
If yes, please explain.
List at least three things you procrastinate at -- list two or three things that you’ve been putting off.
What is getting in the way of these goals?
In what ways would you like your life to be different? Be specific.
What would you like me to do if you get behind in progress toward your goals?
Do you believe in God? If so, in what ways do you sense God might be challenging you, nudging you in a different direction, or trying to get your attention.
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, if any, are your concerns about coaching?
How do you like to be supported or held accountable?
What else would you like me to know about you?
Laura Lawrence Wilcock, CPLC | www.northstarlifecoaching.com | laura@northstarlifecoaching.com | (203) 655-0800
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