Coaching intake form

New clients: Please complete this form at least 24 hours before we meet. You’ll receive an email copy of your submissions.

Thank you!

Basic information about you

Name *

First

Last

Preferred pronouns

(For example: he/him/his, she/her/hers, they/their/theirs)

Email *

Cell phone number *

Alternate phone number

For example, home or work number

Okay to leave messages?

Cell
Alternate phone

Please check all that apply

Mailing Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Emergency contact information

Emergency contact's name *

First

Last

Contact number *

Relationship to you *

Background information about you

Please share as much or as little as you want.

Your age

Anything you’d like me to know about your background & identities (e.g., racial/cultural background, places you’ve lived, education, etc.)?

How you spend your time (work, volunteer roles, hobbies, etc.)

Anything else you’d like me to know about you as a person?

Questions for reflection

These questions are designed to help you identify what you'd like to focus on in coaching. Feel free to jot down whatever comes to mind--no complete sentences required!

What do you want more of in your life? *

What do you want less of in your life? *

What would you try if you knew you would succeed? *

What do you want more than anything? *

What do you do for fun? *

What have you wanted to do, but haven’t? *

What stops you from having the life you want to have? *

What question, if asked right now, would change your life for the better? *

Your priorities for coaching

A few more questions to help you get the most out of coaching.

What I want to accomplish through the coaching process: *

Topics I want to explore or become clearer about: *

What I need most from my coach: *

Any other questions or comments?