Client Intake Consent Form

EMERGENCY

EMERGENCY CONTACT

EMPLOYER/SCHOOL:

WOULD YOU LIKE TO BE ADDED TO OUR EMAIL LIST FOR SPECIALS AND DISCOUNTS?
YesNo

RELATIONSHIP STATUS: (Please check choice)
SINGLEPARTNERSHIPMARRIEDDIVORCED

SIGNIFICANT OTHER'S NAME:

Add if needed

FOR APPOINTMENT SCHEDULING:

COACHING HISTORY:

HAVE YOU BEEN COACHED BEFORE?
YesNo

MEDICAL HISTORY: (Please check off any that apply)

ALCOHOL/DRUG ABUSEADD/ADHDANXIETYEATING DISORDER DEPRESSIONEMOTIONAL ABUSEPHYSICAL ABUSESEXUAL ABUSESUICIDAL IDEATION

ADDITIONAL QUESTIONS:

ARE YOU CURRENTLY TAKING ANY MEDICATIONS?
YesNo

ARE THERE ANY PAST HISTORY OF SURGERIES OR OPERATIONS?

YesNo

DO YOU HAVE TROUBLE FALLING ASLEEP? STAYING ASLEEP?

YesNo

ARE YOU DEALING WITH ANY ADDICTIONS?

YesNo

ARE YOU CURRENTLY SEEING A THERAPIST OR COUNSELOR?

YesNo

HOW WOULD YOU RATE YOUR OVERALL PHYSICAL HEALTH?

ExcellentOutstandingGreatGoodNot BadPoor

HABITS AND GOALS QUESTIONNAIRE:

ARE YOU USUALLY:

EarlyOn-TimeRunning LateLost Track of Time

DO YOU EXERCISE REGULARLY? (Please explain)

DO YOU HAVE HOBBIES?

YesNo

WHAT DO YOU DO FOR FUN?

WHAT ARE YOUR PERSONAL SHORT AND LONG-TERM GOALS? (Include all goals)

WHAT CHANGES WOULD YOU LIKE TO MAKE IN YOUR LIFE RIGHT NOW?

HOW DO YOU DEFINE SUCCESS?

HABITS AND GOALS QUESTIONNAIRE:

ARE YOU USUALLY:

EarlyOn-TimeRunning LateLost Track of Time

DO YOU HAVE HOBBIES?

YesNo

Please explain your hobbies:

COACHING QUESTIONNAIRE:

GOALS FOR COACHING:

Please describe the specific goals you wish to achieve through Life Coaching (Improve Relationships, Increase Productivity, Find Work-Life Balance and Build Life)

EXPECTATIONS:

Please describe your expectations for the coaching process and the results you hope to achieve.

CONSENT:

I understand that life coaching is a collaborative process, and I will be expected to actively participate in the coaching sessions and take action on the goals we set together. I also understand that individual results may vary. Accordingly, life coaching is not intended to transfer knowledge but to help clients recognize their path to knowledge and skills to reach their goals by building and tapping into self-discovery. I understand that life coaching is not meant to provide therapeutic/therapy, psychotherapy, mentoring, career counseling services, teaching, or consulting. Life coaching provides constructive feedback, as this is pertinent for the client to persist in learning and challenging areas of concern that would aid further in self-assessment.
I confirm that I have read and understand the information provided to me, and I consent to receiving life coaching services.

Signature:

Date:

Thank you for providing this information. Your privacy and confidentiality will be respected during our coaching sessions.

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