Client Intake Form
*
1.
Client Name:
(Required.)
*
2.
Describe what is most important for you to get out of this coaching experience.
(Required.)
*
3.
Have you received professional life coaching in the past?
(Required.)
Yes
No
4.
If yes, how long ago?
0-4 years ago
5-9 years ago
+ 10 years ago
Please describe the type of coaching you received in the past, if applicable.
Not applicable
*
5.
Choose the type of industry that best describes your line of work.
(Required.)
Healthcare
Education/ Training/ Development
Finance/ Sales/ Marketing
Retail/ Logistics
Innovation/ Technology
Other (please specify)
6.
Please rate your current physical health and energy level.
Poor
1 star
Fair
2 stars
Good
3 stars
Very Good
4 stars
Excellent
5 stars
7.
Please rate your current time management skills.
Poor
1 star
Fair
2 stars
Good
3 stars
Very Good
4 stars
Excellent
5 stars
8.
Please rate your current financial stability.
Poor
1 star
Fair
2 stars
Good
3 stars
Very Good
4 stars
Excellent
5 stars
9.
Please rate your overall relationships/ connection with people you care about.
Poor
1 star
Fair
2 stars
Good
3 stars
Very Good
4 stars
Excellent
5 stars
10.
Please rate your overall ability to regulate your own emotions.
Poor
1 star
Fair
2 stars
Good
3 stars
Very Good
4 stars
Excellent
5 stars
11.
Please rate your overall engagement and satisfaction with your job/ work.
Poor
1 star
Fair
2 stars
Good
3 stars
Very Good
4 stars
Excellent
5 stars
12.
Please rate how well you are contributing back to society or helping others.
Poor
1 star
Fair
2 stars
Good
3 stars
Very Good
4 stars
Excellent
5 stars
