Section 1 of 1
Potential Client Questionnaire
By completing this form, you will help me better understand your needs, goals, and how my services can best support you.
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Full Name:
Full Name:
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Date of Birth:
Date of Birth:
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Gender
Gender
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Male
Female
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Phone Number:
Phone Number:
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Best Email Address:
Best Email Address:
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Physical Address:
Physical Address:
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Place of Employment:
Place of Employment:
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How did you hear about us:
How did you hear about us:
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Preferred Language
Preferred Language
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What areas of your life would you like support with?
What areas of your life would you like support with?
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Relationships / Self or Other
Mental Health
Faith
Family Dymanics
Career / Prof Development
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What is your biggest challenge or struggle right now?
What is your biggest challenge or struggle right now?
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Have you worked with a coach, counselor or mentor before?
Have you worked with a coach, counselor or mentor before?
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Yes
No
Not Sure
When I Was Younger
Pastoral or Lay Counseling Through Church
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What specific goals would you like to achieve through coaching?
What specific goals would you like to achieve through coaching?
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How ready are you to make changes in your life?
How ready are you to make changes in your life?
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0
1
2
3
4
5
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8
9
10
1
Label (optional)
10
Label (optional)
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What does success look like for you in this area?
What does success look like for you in this area?
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How often do you anticipate needing coaching sessions?
How often do you anticipate needing coaching sessions?
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1.
Weekly
2.
Bi-weekly
3.
Monthly
4.
As needed
5.
On demand
6.
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What days work best for you for coaching sessions?
What days work best for you for coaching sessions?
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Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
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What times work best for you?
What times work best for you?
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Morning
Afternoons
Evenings
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Are you comfortable with virtual sessions, or do you prefer in-person sessions (if available)?
Are you comfortable with virtual sessions, or do you prefer in-person sessions (if available)?
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1.
Virtual at the comfort of my home / office / or desired place
2.
In-Person at home or public place
3.
No Preference
4.
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Would you like coaching that integrates faith and biblical principles?
Would you like coaching that integrates faith and biblical principles?
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Yes
No
Unsure
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Have you ever been diagnosed with a mental health disorder? If so please explain when and what disorder:
Have you ever been diagnosed with a mental health disorder? If so please explain when and what disorder:
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Are you currently taking any medications? If yes, please explain:
Are you currently taking any medications? If yes, please explain:
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In the past two weeks, how many days have you felt little to no interest or pleasure in activities you once enjoyed?
In the past two weeks, how many days have you felt little to no interest or pleasure in activities you once enjoyed?
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None
Several days (4–6 days)
More than half the days (7–11 days)
Nearly every day (12–14 days)
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What is one things that you have accomplished in the last year?
What is one things that you have accomplished in the last year?
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Share one thing that you feel accomplished about in your personal and professional life:
Share one thing that you feel accomplished about in your personal and professional life:
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Do you have any specific questions or concerns about coaching that you’d like to discuss during the initial session?
Do you have any specific questions or concerns about coaching that you’d like to discuss during the initial session?
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Would you like to schedule a free 15 minute consultation? If yes, please provide your availability.
Would you like to schedule a free 15 minute consultation? If yes, please provide your availability.
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Are you interested in a coaching package? Coaching packages are designed to provide structured support and greater value. Packages typically include a set number of sessions (e.g., 4, 6, or 12) at a 5 to 10 % discounted rate, along with additional resources such as worksheets, guides, and follow-up emails to help you stay on track. Choosing a package ensures accountability and consistent progress toward your goals.
Are you interested in a coaching package? Coaching packages are designed to provide structured support and greater value. Packages typically include a set number of sessions (e.g., 4, 6, or 12) at a 5 to 10 % discounted rate, along with additional resources such as worksheets, guides, and follow-up emails to help you stay on track. Choosing a package ensures accountability and consistent progress toward your goals.
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Yes
No
Maybe
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