Client Intake Form COACHING CLIENT INTAKE FORM Please fill in this form and answer the questions below as clearly and thoughtfully as possible, expressing the best of who you are. These questions are designed to stimulate your thinking in a particular way that will make our work together even more productive. As your coach, it is important for me to understand your goals, your history, and how you view the world in general and yourself in particular. You may write as much or as little as you like and feel free to skip the questions that do not apply to you. First Name Surname Marital StatusSingleCommon LawMarriedSeparatedDivorcedWidowed Birthdate Mailing Address Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code AfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongoCongo (Brazzaville)Costa RicaCote d'IvoireCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorth MacedoniaNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth SudanSpainSri LankaSudanSurinameSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWalesYemenZambiaZimbabwe Country Home Phone Cell Phone * Business Phone Best Number To Reach You*Cell PhoneHomeBusiness Email Address* Payment Method PaypalWire TransferE-Transfer (Canada) Paypal Email (Payment Required Before Coaching) What Are Your Goals? What are the three biggest changes you want to make in your life in the next 4 months? * What are the three to five biggest changes you want to make in your life over the next 3 years? * If there were a secret passion in your life that you would like to pursue, what would that be? * What would you say have been your 3 greatest accomplishments in your life to date? * What is (are) the hardest thing(s) in your life that you have had to overcome? * Who are, or have been, your major role models? * Have you ever worked with a professional coach before or been in a similar one-on-one adult relationship (e.g., tennis coach, piano teacher, counsellor, therapist)? Please describe the relationship(s). * If yes, please explain what worked well for you and what did not work in the relationship(s)? * What, if any, major transitions have you had in the past two years? Entering or approaching a new decade of life, a new relationship, a new job, a new role, a new residence, change in children's ages/stages, etc.? * Please list any improvements you would like to make in any of the following areas of your life? 1.) Health and Wellbeing 2.) Family / Home life 3.) Financial situation 4.) Business / Work / School 5.) Personal Character 6.) Relationships* On a scale of 1 to 10 (with 10 being the highest), rate the quality of your life today. *10987654321 I consent collecting this data and processing it according to Privacy Policy of this website.SubmitReset
