Intake Form

General Information

Name

First Name

Last Name

Cell Phone

(###)

###

####

Other Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

YYYY

Gender

Marital status or relationship

Names and ages of children

Referred by

Health

How would you rate your current physical health?

How many times per week do you usually exercise?

Do you de-stress on purpose?

Yes

Sometimes

What do you do for exercise?

Have you been injured?

Have you been hospitalized?

Any history of addiction, dysfunction or mental illness in your family history?

Please list any specific health problems you are currently experiencing.

Are you currently smoking, drinking or using drugs?

Are you on any prescription medications?

How would you rate your current mental health?

How would you rate your current emotional health?

Family (please list what is going well, average or poorly)

Relationship with mother:

Relationship with father:

Relationship with siblings:

Work

Where do you currently work?

What is your position?

Do you enjoy your work?

Describe the team.

Describe your boss.

Describe the culture at the company.

Is there anything stressful about your work?

What is your current financial situation?

Goals

What are the biggest changes you want to make in your life in the next three months?

What are the biggest changes you want to make in your life in the next three years?

What do you most want to achieve for yourself in your life/career?

What are the restraining forces keeping you from achieving these results?

What do you expect to achieve as a result of hiring me as your coach/consultant?

Who will be supporting you through this process?

History

What have been your top 3 biggest accomplishments to date?

What has been your biggest failure to date?

What’s the hardest thing in your life that you have had to overcome?

What major transitions or life changes have you had in the past two years? (Example: Entering or approaching a different age, a new or different relationship, job role, residence, a change in children’s ages/stages, etc.)

Who are or have been your major role models? Why?

Have you worked with a coach before or a similar one-on-one adult relationship (e.g. tennis coach, piano teacher, and therapist)? If so, what worked well for you and what did not work in the relationship(s)?

What else would you like to share with me about your life story or history?