Name
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Street Address
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City, State/Province, Zip/Postal Code
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Country
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Date of birth
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MM
DD
YYYY
Current age
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Place of birth
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Email address
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Cell phone
(###)
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Home phone
(###)
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Work phone
(###)
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Best number to reach you
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Best time of day to reach you
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Emergency contact name and phone number(s)
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Current occupation including your position/role
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Length of time in your current occupation
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Responsibilities in your position/role
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Name of company or business where you are employed
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Location of company or business (city & state only)
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Previous occupations/professions
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Highest level of education
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Other areas of study that interest you
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How do you learn the best? (check all that apply)
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Current marital dynamic (check one)
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Name of spouse/partner and their occupation
Names and ages of children
Names and ages of siblings
I would describe my religious background as (check one)
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I would describe my current religious affiliation as (check one)
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Are you currently an active participant in the religious affiliation you chose above?
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Do you drink alcohol more than once a week? If so, how often?
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Do you engage in recreational drug use? If so, what drug(s) and how often?
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Describe your overall health and fitness level:
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Are there any health factors that limit your lifestyle or ambitions?
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How would you rate your current sleep experience on a 1 to 5 scale with 5 being the best?
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What significant life changes or stressful events have you experienced recently?
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Are you currently seeing a therapist, or have you seen a therapist in the past? If so, who, and for what reason(s)?
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Are you currently taking medication(s) for a mental health challenge? If so, please list the medication(s).
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My greatest strengths are...
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My favorite activity or activities include...
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What are the best parts of your life currently?
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What do you dream about doing (what makes your heart sing)?
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What do you need most from me as your coach?
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What topics do you want to explore in your coaching sessions?
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What expectations or goals do you have from our relationship?
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What other things would you like me to know about you?
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Do you have any additional questions, comments or concerns?
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Lastly, please tell me who referred you, or how you heard about me...