Client Intake Consent Form

PERSONAL INFORAMATION:

NAME: _____________________________________________________________

DATE OF BIRTH: _____________________________________________________

AGE: _______________________________________________________________

 ADDRESS: _________________________________________________________

 STATE:________________CITY:__________________  ZIPCODE:___________

TELEPHONE:_______________________ CELLPHONE:_____________________

EMAIL: _____________________________________________________________

EMERGENCY CONTACT:______________________________________________

EMERGENCY CONTACT NUMBER:______________________________________

EMPLOYER:__________________________________________________________

 SCHOOL    :__________________________________________________________

OCCUPATION_________________________________________________________

YEARS IN SCHOOL: :__________________ HIGHER EDUCATION::_____________

EMPLOYER/SCHOOL:

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

•  Yes
•  No

RELATIONSHIP STATUS: (Please check choice)

•  SINGLE
•  PARTNERSHIP
•  MARRIED
•  DIVORCED

SIGNIFICANT OTHER’S NAME: ____________________________________________

CHILDREN’S NAMES_______________________________ AND AGES: ____________

Add if needed

FOR APPOINTMENT SCHEDULING:

• WHAT ARE YOUR PREFERRED TIMES OF DAY?______________________
• DAYS OF THE WEEK? _____________________________________

COACHING HISTORY:

HAVE YOU BEEN COACHED BEFORE?

•  Yes
•  No
• IF YES, PLEASE SHARE YOUR EXPERIENCE:

MEDICAL HISTORY: (Please check off any that apply)

•  ALCOHOL/DRUG ABUSE
•  ADD/ADHD
•  ANXIETY
•  EATING DISORDER
•  DEPRESSION
•  EMOTIONAL ABUSE
•  PHYSICAL ABUSE
•  SEXUAL ABUSE
•  SUICIDAL IDEATION
•  OTHER (Please specify): ________________

ADDITIONAL QUESTIONS:

ARE YOU CURRENTLY TAKING ANY MEDICATIONS?

•  Yes
•  No
• If yes, please list the medications and their purposes:

ARE THERE ANY PAST HISTORY OF SURGERIES OR OPERATIONS?

•  Yes
•  No
• If yes, please provide details:

DO YOU HAVE TROUBLE FALLING ASLEEP? STAYING ASLEEP?

•  Yes
•  No
• If yes, please describe the sleep issues you experience:

ARE YOU DEALING WITH ANY ADDICTIONS?

•  Yes
•  No
• If yes, please specify the nature of the addiction(s):

ARE YOU CURRENTLY SEEING A THERAPIST OR COUNSELOR?

•  Yes
•  No
• If yes, please provide the reason for therapy and the frequency of sessions:

HOW WOULD YOU RATE YOUR OVERALL PHYSICAL HEALTH?

•  Excellent
•  Outstanding
•  Great
•  Good
•  Not Bad
•  Poor

HABITS AND GOALS QUESTIONNAIRE:

ARE YOU USUALLY:

•  Early
•  On-Time
•  Running Late
•  Lost Track of Time

DO YOU EXERCISE REGULARLY? (Please explain)

If yes, please describe your exercise routine and frequency:

DO YOU HAVE HOBBIES?

•  Yes
•  No

If yes, please explain your hobbies and how often you engage in them:

WHAT DO YOU DO FOR FUN?

Please describe activities you enjoy for recreation and relaxation:

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

Please list both short-term and long-term goals you wish to achieve:

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

Describe any specific changes or improvements you seek in your life:

WHAT DIFFICULTIES KEEP YOU FROM REACHING YOUR GOALS?

Please identify any challenges or obstacles you face in pursuing your

goals:

HOW DO YOU DEFINE SUCCESS?

Share your personal definition of success and what it means to you:

HABITS AND GOALS QUESTIONNAIRE:

ARE YOU USUALLY:

•  Early
•  On-Time
•  Running Late
•  Lost Track of Time

DO YOU EXERCISE REGULARLY? (Please explain)

DO YOU HAVE HOBBIES?

•  Yes
•  No

Please explain your hobbies:

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

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

• WHAT DIFFICULTIES KEEP YOU FROM REACHING YOUR GOALS?

• HOW DO YOU DEFINE SUCCESS?

COACHING QUESTIONNAIRE:

• WHY HAVE YOU DECIDED TO WORK WITH A LIFE COACH?

• WHAT PART OF YOUR LIFE IS WORKING WELL?

• WHAT PART OF YOUR LIFE COULD BE WORKING BETTER?

• IS THERE ANYTHING ELSE YOU WOULD LIKE ME TO KNOW?

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)

HOW LONG HAVE YOU BEEN THINKING ABOUT THESE GOALS?

WHAT STEPS HAVE YOU TAKEN SO FAR TO ACHIEVE THESE GOALS?

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.