Intake Form Your Name: Preferred Name: Age: —Please choose an option—18192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899 Preferred pronouns: —Please choose an option—he/himshe/herthey/themother Phone Number: Your Email: REASON FOR INQUIRY: Are you looking for coaching? If yes, what type? (Life, health/fitness, relationship, sex, etc. Be specific.) Are you looking for couples coaching? If yes, what type? PAST COACHING: Have you ever had any previous types of support such as other coaching, counseling or therapy? If so, how long and what for? Did it work for you? Why did you enter and why did you leave? Rate your experience on a scale of 0 to 10. (0 worst and 10 best) 012345678910 GOALS: Why are you seeking coaching and what for? What specifically would the perfect outcome look like when our coaching experience is completed? What might stand in your way? Do you have any other support for reaching your goals? Have you tried reaching these goals on your own? If so, in what way? How has that been working for you? When would you like to start? How can I best hold you accountable for your goals? Be specific. Are there any other important things I need to know about you that would be important for our working together? Structure: How much time can you commit to achieving your goals? How much time can you commit to coaching? What platforms are available to you? textemailphoneonlinein-person Δ
