Personal Coaching Intake Form

Welcome!

Let's start with some basic information about you. This coaching journey is all about your personal growth and transformation.

Full Name *

Age

Email *

Phone Number *

Current Location (City, State)

Relationship Status

Current Occupation

Your Journey Begins

Understanding what brings you to coaching helps us create a roadmap for your transformation.

What brings you to life coaching at this time? *

What are your main goals for this coaching experience?

Have you worked with a coach or therapist before?

Yes, with a coach Yes, with a therapist Yes, with both No, this is my first time

On a scale of 1-10, how motivated are you to make changes in your life? *

Not motivated Extremely motivated

Wheel of Life

Rate your current satisfaction in each life domain on a scale of 1-10. This helps us identify areas that need attention.

Career & Work

How satisfied are you with your career and professional life? *

Finances

How satisfied are you with your financial situation? *

Health & Wellness

How satisfied are you with your physical health and wellness? *

Relationships & Love

How satisfied are you with your romantic and family relationships? *

Which life domain needs the most attention right now? *

Your Core Values

Values guide your decisions and give your life meaning. Let's identify what matters most to you.

List your top 5 personal values (what's most important to you in life):

Examples: Honesty, Creativity, Family, Growth, Freedom, Love, Success, Adventure, Peace, Service, etc.

Value #1:

Value #2:

Value #3:

Value #4:

Value #5:

How well are you currently living in alignment with your values? *

Not at all aligned Perfectly aligned

What obstacles or challenges are preventing you from living more in line with your values?

Faith & Spirituality

Understanding your spiritual life helps us integrate what matters most to you.

How important is faith/spirituality in your life? *

Very important - central to my daily life Somewhat important Not very important I'm exploring spirituality

Would you describe yourself as:

Are you open to faith-based approaches in our coaching work? *

Yes, I prefer it I'm open to it I prefer secular approaches

Your Strengths & Growth

Let's identify what you're already good at and where you want to grow.

What are your top 3 personal strengths or positive qualities?

Examples: Resilience, Creativity, Kindness, Leadership, Humor, Persistence, etc.

What are 2-3 areas where you'd like to grow or develop?

Are you currently experiencing any mental health challenges?

No Yes, mild anxiety or stress Yes, moderate challenges (anxiety, depression, etc.) Yes, currently working with a therapist

How did you hear about our coaching program?

Understanding & Agreement

Please read each statement carefully and provide your initials to indicate your understanding and agreement.

I understand that this is a coaching relationship, not therapy or clinical counseling. Those needing clinical work will be referred to appropriate licensed professionals.

I understand that coaching employs various techniques and approaches that are flexible and tailored to my unique needs. The focus is on achieving desirable outcomes and fostering healthy growth rather than dwelling on past problems.

I understand that all information shared is kept confidential except in three primary areas: 1) suicidal ideations or intent, 2) child or elderly abuse and/or neglect, and 3) homicidal ideations or intent.

I understand that my coach reserves the right to refer me to another coach or licensed professional should they deem it in my best interest.

I commit to being on time for sessions, honest in my communication, and actively engaged in my personal growth process. I understand that the value of coaching depends largely on my willingness to be open and do the work.

Full Name (Signature) *

Date *

Personal Coaching Intake

Personal Life Coaching