Coaching Intake Form

COACHING INTAKE FORM

Personal Information: Date of Birth:________ ___ Age:_____ Gender: M / F

First Name

COMMENTS / NOTES

Last Name

Address

City

State

Zip/Postal Code

Phone

Email Address

The issue of confidentiality is paramount to this relationship. My understanding is that nothing in this

relationship is to be discussed outside of our conversations. There are times when references to others

may be helpful, however, I would not ever mention a name or person that would lead someone to infer

the discussion was about you as a client.

What do you want to change or improve now?

How will you know when you have achieved what you want?

What is most important to you in your life and how do you know that?