Name
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First Name
Last Name
Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
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Phone Number
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Date of Birthday
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MM/DD/YYY
MM
DD
YYYY
How Do You Want Your Confirmation Sent
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Please allow up to 48 hours as we review your intake form and create the best package for you.
The Start Up Consultation usually takes 35mins-1 hour. Please arrange time before picking your date & time.
Please Provide / Consultation Desire Time/ Date / In-Person or Over The Phone
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Confirmation will be sent to preferred follow up contact
What are the biggest changes you want to make in your life in the next 3 months?
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Name up 3 things.
What are the biggest changes you want to make in your life over the next 3 years?
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List 3 things
What do you most want to achieve for yourself in your life/career?
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What are the restraining forces keeping you from achieve these?
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What would you say have been your 3 greatest accomplishments to date?
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What do you expect to achieve in life as a result of hiring me as your life coach?
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What is the hardest thing in your life that you have had to overcome?
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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.)
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Who are or have been your major role models? Why?
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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)?
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Who will be supporting you through this process?
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Your Life Story / History:
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What would you like to share with me?
On a scale of 1 to 10 with 10 high, rate the quality of your life today.
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List five things that you’re personally tolerating or putting up with in your life at present.
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(Examples: information you can’t find, clutter, rude friends, tight shoes, dented car, job dissatisfaction, dead plants, broken equipment, cranky people in your life etc.)
In a typical week, what do you spend a great amount of time doing?
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What are your primary stressors?
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(What stresses you out?)
On a scale of 1 to 10, 10 high, rate the amount of stress in your life right now
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Family:
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Money / Financial Situation:
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Career / Business life:
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Service / Personal Character:
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Relationships:
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Friends:
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Living Space / Home:
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Personal Growth / Learning:
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Health / Self Care:
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Creativity:
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Play / Leisure time:
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Hobbies:
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What do you spend most of your leisure time doing?
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