Client Intake Form

A quick questionnaire about your life/ goals/ challenges/ questions for me.

Full Name

What are the main reasons you are interested in coaching?

Have you tried working on any of this before? How did it go?

What's missing from your life that you really want?

Where do you want to be 3-6 months from now? What goals would you like to have achieved? What would you be excited about?

What are some milestones that will indicate that we are moving in the right direction?

Why is now the right time for you to prioritize these goals?

What do you think holds you back the most?

What do I need to know about you (and how you make changes) that will help me most in coaching you?

Are you currently in therapy? Please share any information that you think will be helpful in our coaching relationship.

Do you have any questions you want to make sure I answer?

Please provide an emergency contact and include their:

- full name - relationship to you - phone number

What's your mailing address?

What's your birthday?