Consultation Intake Form

Name

Email

Address

City

State

Zipcode

Age

Job/Place of Work

Spouse/Partner's Name (if applicable)

Children's Names/Ages (if applicable)

What issues would you like to work on? What do you hope to achieve through coaching?

1. I would describe myself as...

2. Others would describe me as...

3. The three things that I like most about my life/situation are...

4. If I could change three things about my life/situation, they would be...

5. My three greatest accomplishments (so far) are...

6. Some of my hobbies/interests are...

7. The one thing I would like to accomplish (but haven't yet) is...

8. The one thing I wish I could change in the short-term is...

9. I think that the most important thing in life is...

10. I am interested in working with a life coach because...

Disclaimer Consent Disclaimer Consent By checking this box, I acknowledge that a coaching relationship does not represent psychological counseling or any kind of therapy. I am also aware that coaching results can vary and are not guaranteed. I understand that I am responsible for my own decisions and results. I also agree to hold the Coach free from all liability for any actions or results for adverse situations created as a direct or indirect result of advice given by the Coach.