Coaching Intake Form

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Coaching Intake Form
General Information:
Today’s Date: _________________
Your Name: _________________________________ Address: ______________________________________________
City: ____________________________________________ State: ______________________ ZIP: _________________
Cell Phone: _____________________ Home Phone: _____________________ Work Phone: _____________________
Email: _______________________________
Male
Female Age: ________ Date of Birth: __________________
Place of Birth: _______________________ Ethnicity/Nationality
_____________________________________
(optional):
Relationship Status: __________________ Number of Children _____ Ages of Children _________________________
Education:
High School
Some college
BA/BS
MA/MS
Ph.D.
Other _____________________________
Field of Study: _________________________ Additional Background: ________________________________________
Company Name: _________________________________ Occupation/Title: ___________________________________
Preferred Phone #:
Cell
Home
Work Best Dates/Times to Reach You: ________________________________
Your Goals:
What three goals would you like to accomplish within the next three months?
1. ________________________________________________________________________________________________
2. ________________________________________________________________________________________________
3. ________________________________________________________________________________________________
What one major goal would you like to accomplish within the next twelve months?
__________________________________________________________________________________________________
What has been your greatest challenge?
__________________________________________________________________________________________________
What do you expect to achieve as a result of hiring me as your coach?
__________________________________________________________________________________________________
On a scale of 1 to 10 (10 as high), rate the quality of your life ______ your health ______ the amount of stress ______
Here are ways of coaching clients. Which ones appeal to you?
Brainstorming strategies together
Support, encouragement and validation
______
_______
______
Insight into who you are and your potential _______ Paining a vision of what you can accomplish
______
Accountability; checking up on goals
_______
Exploring/removing blocks to your success
Suggesting or designing action steps
Working through self-improvement programs together
______
_______
Any additional questions or comments: _________________________________________________________________
__________________________________________________________________________________________________
Provided by Power Living Enterprises, Inc. Please fax back to 212-901-6913 or email to .

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