Coaching Intake Form

Name

First Name

Last Name

Phone Number

Area Code

Phone First 3

Phone Last 4

Date of Birth

Occupation/Career

Relationship Status

Children and their ages

Areas of life you want coaching

What 3 specific goals do you want to achieve in the next three months?

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

What is your main goal for our coaching sessions?

What would you say have been your three greatest accomplishments in your life to date?

What is the hardest thing you have had to overcome?

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

What major transitions have you had in the past two years?

Who are they key people in your life and what do they provide for you?

Is your life one of your choosing? If not, which parts are being chosen for you?

On a scale of 1-10, 10 being highest, provide a number that represents your current level/degree of stress

What are your primary stressors?

List 5 things that you are tolerating or putting up with in your life at present

How will you know when you are receiving value from the coaching process?

What types of approaches discourages you or take away your motivation?

How will you know I am the right coach for you?

Do you have a professional vision?

What would you like to contribute to the world?

What is a dream or goal you have given up on?

What part of yourself, if any, have you give up on?

On a scale of 1-10, rate the overall quality of your life today

What would you love to have, be or do, in/with your life that you don't have now?

What is stopping you from having, doing or being who or what you desire?

How would you be different is you could have, do or be what you desire?

Is there anything you don't normally share with others that as your coach, you feel it is important for me to know?

Is there anything else you want me to know before our first session?

Are you prepared to commit time, money and energy to your coaching plans?

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