Intake Form

Interested if coaching is right for you? working together? Fill out some info and we will be in touch shortly! We can't wait to hear from you!

Name

First Name

Last Name

Age

Gender and pronouns

Address or geographic area

Phone

(###)

###

####

Preferred method of communication

Offer preferred and back-up, please

Best time to reach you

Name / relationship of significant people in your life

Occupation / employer

Educational and career background

Activities / responsibilities

What's currently on your plate?

Responsibilities that are not getting attention

What are some of your strengths?

Problem solver, creative, good listener, etc.

What are some of your talents?

Activity specific-gifted horse trainer, painter

How do you best learn or convey information?

Think about asking for or giving directions: Do you prefer a picture or map (visual)? Do you prefer being told (auditory)? Do you need to draw the map (kinesthetic)? Talk it through (verbal)? Share whatever works for you!

What are your two biggest challenges?

How long have you experienced these challenges?

What are your current systems?

Day planner, routine for getting out the door in the morning, etc.

How do you take care of yourself?

Self care, sleep habits, exercise, eating, etc.

Do you have any diagnoses that may impact our work together?

Who is on your support team?

Other professionals, too?

How do you utilize support?

Subordinates, colleagues, assistants, etc.

What do you want to have happen?

Who is the most powerful person you are becoming? (your future self)

How do you get in your own way?

Think habits and behaviors that keep you from getting what you want

How well do you accept praise?

How well do you accept criticism?

How are your boundaries?

Are they well defined or vague?

Do people know where they stand with you?

Can you say “no” to requests?

What works best to support you moving forward?

What do you want from our coaching relationship?

Such as accountability, support, etc.

How much time do you spend reviewing and planning actions?

How do you want me to respond if you do or don’t complete a homework assignment?

How do you want me to respond if you disappear?

What makes you laugh?

What else would you like me to know about you?