Creative Capacities LLC CONFIDENTIAL Client Information Form All information you provide is held in the strictest confidence. Question Title * 1. Please provide your contact information. Name Company Address Address 2 City/Town State/Province ZIP/Postal Code Country Email Address Phone Number Question Title * 2. Full Birth Date Question Title * 3. Age Question Title * 4. Marital Status Single Married Engaged Widowed Divorced Other (please specify) Question Title * 5. Children Names and Ages Question Title * 6. Are you on any medications that I should be aware of? Question Title * 7. Do you have any health or mental health conditions I should be aware of? Question Title * 8. What are your top 5 personal strengths or talents? Strength/Talent 1 Strength/Talent 2 Strength/Talent 3 Strength/Talent 4 Strength/Talent 5 Question Title * 9. What are the three most important things we should focus on in this coaching engagement over the next 3 months? Important Item 1 Important Item 2 Important Item 3 Question Title * 10. What are you putting up with that is holding you back? (i.e. unhealthy relationship, recurring problem, unproductive habits, etc.) Holdback 1 Holdback 2 Holdback 3 Done