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Potential Client Questionnaire
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Full Name:
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Date of Birth:
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Gender
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Phone Number:
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Best Email Address:
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Physical Address:
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Place of Employment:
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How did you hear about us:
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Preferred Language
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What areas of your life would you like support with?
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What is your biggest challenge or struggle right now?
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Have you worked with a coach, counselor or mentor before?
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What specific goals would you like to achieve through coaching?
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How ready are you to make changes in your life?
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What does success look like for you in this area?
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How often do you anticipate needing coaching sessions?
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What days work best for you for coaching sessions?
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What times work best for you?
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Are you comfortable with virtual sessions, or do you prefer in-person sessions (if available)?
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Would you like coaching that integrates faith and biblical principles?
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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:
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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?
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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:
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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.
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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.
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