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I would like to become more
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Social
Confident
Productive
Fun-Loving
Educated
Creative
Artistic
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Skilled
Physically Active
Thoughtful
Giving
Grateful
Loving
Affectionate
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Goal-Oriented
Religious
Healthy
Financially Stable
Independent
Self-Assured
Kind
Free-Spirited
Playful
Happy/Content
Bucket List: List three things you would love to do if there was no time, money or consequence involved
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Goals: Which items off of the wish list stand out as your top 3
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Client Intake Form
The five ways I'd like to grow in the next year
1. I could
By
2. I could
By
3. I could
By
4. I could
By
5. I could
By
Intake Questions
What do you feel are the most important problems right now?
What problems do you feel are solvable?
What problems do you feel are NOT solvable?
What do you see as the obstacles to solve these problems?
What feeling would you like to have MORE of?
Is there a particular person in your life that you feel may stop you from moving forward?
What is the most pressing thing on your mind that you feel you would like to share with me?
If you asked your friends what you should work on in your life, what would they say?
What are the 3 ways you feel i can help you most?
Short answer
What is the ONE regret you don't want to have in your lifetime?
What is the ONE regret you don't want to have in your lifetime?
Are you willing to try new ways of doing things to move forward in your life?
What has been the MOST fulfilling thing that you've accomplished in your life (so far)?
Who or what is holding you back the most right now?
How much stress are you under right now?
Where does the stress come from?
Who are the key people in your life? Tell me a little about them
What parts of your life do you feel are NOT of your choosing?
Client Priorities
1. Write ONE sentence each, I'd like to change my life in these 3 ways:
2. I want to improve my life skills in the following areas:
3. If I had a magic wand, I would wish that _________________ (a person) would do one of these three things: (circle one)
a. Treat me differently.
b. Understand me better.
c. Disappear into thin air.
4. If it was impossible for me to fail, I would like to:
5. If I had all the time in the world, I would be doing:
Client Information Form
Name
Address
City/State/Zip:
Marital Status:
Married
Unmarried
Email
Phone
Home
Cell
Is it OK to leave a message?
Birthday
Month
Day
Year
Age
Where did you hear about my services?
Have you experienced coaching before?
Are there any medical conditions I need to be aware of?
If yes, please list the condition and any medications you take:
If yes, please list the condition and any medications you take:
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