Client Intake Form (3 Months Coaching program)

Client Intake Form

(3 Months Coaching Program)

Full Name*

Preferred Name*

Date of Birth*

Email*

Phone Number*

Preferred Method of Contact:*

Phone

Best Days/Times for Sessions:*

Current Occupation/Profession

Briefly describe your professional and personal background

What motivated you to join this coaching program?

List your top three goals you wish to achieve in the next 3 months*

Describe your long-term vision for yourself (in the next 1-5 years)*

How do you envision this coaching program helping you achieve your goals?

What are your top strengths and talents?

Which areas do you feel need improvement or development?

Have you previously worked on these areas? If so, what strategies have you tried?

What are the main challenges or obstacles currently preventing you from achieving your goals?

How have these challenges impacted your personal or professional life?

What have you attempted in the past to overcome these challenges?

What are your core personal values? (e.g., integrity, creativity, compassion)

What motivates you to pursue your goals?

Who or what inspires you?

What is your preferred learning style?*

Visual (seeing)

Auditory (hearing)

Kinesthetic (doing)

Reading/Writing

How do you prefer to receive feedback and guidance?

Are there any specific coaching techniques that resonate with you?

On a scale of 1-10, how committed are you to making the changes necessary to achieve your goals?*

(1) not committed

(5) Likely to commit

(10) fully committed

How much time per week can you dedicate to coaching sessions and related activities?

Do you have a support system in place (friends, family, colleagues) to assist you during this journey?

Yes

Is there any other information you'd like to share that would help us understand you better? If yes, please tell us

In case of an urgent situation needing immediate support, what is the best way to contact you?

Do you consent to session recordings and note-taking for the purpose of enhancing your coaching experience?*

Yes

Please confirm that all information provided is accurate to the best of your knowledge:*

I confirm

Client Signature*

Empowering individuals and organizations to achieve peak performance and fulfillment through neuroscience-backed coaching on goal setting, life purpose, and happiness

Client Intake Form

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