New Client Intake Form

Contact Details

Name*

Email*

Home telephone*

Mobile*

Date*

Emergency contact*

Home address*

Employment Information

Occupation*

Employer/Business name*

Work telephone*

Personal Information

Date of birth*

Marital status*

Do you have children?*

How many children do you have?

Are you being treated for any of the following mental illnesses by a professional health care practitioner?*

Depression
Anxiety
Multiple Personality Disorder
Eating Disorders
None Of The Above

Are you being treated for any of the following addictions by a professional health care practitioner?*

Drugs
Alcohol
None Of The Above

Where is it okay for me to leave messages?*

Is the email address appropriate for me to forward information regarding our coaching?*

What is your preferred means of communication?*

Names of the significant others in your life, and your relationship to them:*

What influenced your decision to work with a coach?*

Have you been coached prior to this?*

If so, describe the coaching experience:

More About You

As your coach it is important that I understand how you view the world in general and yourself in particular. Every person has their own unique and personal method of interacting with their surroundings.

The below questions will help provide me with a method to understand you and your current situation more closely. These questions will enable me to coach you to the best of my ability to be bring out your truest self.

Please take a little time to answer these questions from the heart and as clearly as possible. These questions are designed to be “thought over” and to stimulate your thoughts on items that may have been in the past on autopilot to you.

If you have any queries, please let me know and we can openly discuss them.

What is it that currently occupies the majority of your time and effort personally and professionally?*

What do you do during a normal day?*

What are your business goals?*

What are your personal goals?*

What skills or knowledge are you developing?*

What are your key benchmarks for your goals?*

How does what you do professionally contribute to achieving your personal goals?*

If you could change some aspects of your professional situation, what would you choose to change?*

If you could change some aspects of your personal life, what would you choose to change?*

What do you consider to be your greatest accomplishment so far, personally or professionally?*

What activities are you passionate about?*

Do you know your preferred style of learning?*

If so, what is it?

How do you find you are best motivated?*

What do you believe to be your most important values?*

Do you believe you are living congruently with the values?*

How do you respond when you are in a really challenging situation?*

What are three steps you could take immediately that would make the greatest difference in your current situation(s)?*

What are your specific desired outcomes from the coaching? If you're not sure, thats okay... What might you like to experience more of in your life? Less of? Differently?*

What are your significant commitments?*

What would your ideal life look like?*

What are your dreams?*

What dreams have you given up on?*

Goals

What are your top 5 goals, either short or long term, at the moment?*

Challenges

What are your top 5 challenges at the moment?*

Coaching

What are your major objectives or gains that you wish to achieve from coaching?*

What can I say or do when you are "stuck" that will help you return to action?*

How do you want me to be as your coach?*

We want your coaching to be a beneficial experience for you. This is determined by our beliefs & the rules we have about coaching & its ability to contribute to the quality of our lives. What do you need to believe for coaching to have the biggest effect on your life?*

What, if any, expectations do you have of our coaching together?

Final Words

What else would you like to say?

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Phone

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NEW CLIENT PROFILE