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Life Coaching Intake Form

Please answer these questions to the best of your ability to ensure we understand your needs.

*Virtual Sessions Only At This Time

*Self Pay Only

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Todays Date: *
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Date of Birth: *
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Name *
First and last name
Email *
Mailing Address *
Phone number: *
Emergency Contact - Name and Phone Number:
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Reason for seeking coaching: *
This helps us identify your goals and motivations for seeking coaching. What do you hope to achieve through coaching?
What is your current level of satisfaction with your life?
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This will help us understand your current level of fulfillment and identify areas that may need more attention or support.
What is your preferred mode of communication? *
This will help us understand your communication style and adapt our approach accordingly, whether that's via email, phone, or virtual.
Are there any medical or mental health concerns we need to be aware of?
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This helps us in providing safe and appropriate support for you.
Current challenges:
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This is to help identify any barriers or challenges that you are currently facing so we can develop a plan to overcome them.
How do you typically handle stress or challenges? *
This will help us understand your coping mechanisms and identify any areas that may need more support
Do you have previous life coach experience? *
Do you have previous therapy experience? *
Are you currently seeing a life coach or therapist? *
Area of Focus:
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Help us understand the specific areas of your life that you want to focus on, such as career, relationships, or personal development.
Goals: *
This is to help identify your short-term and long-term goals so we can develop a plan to achieve them.
Preferred Coaching Style:
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Different clients may have different preferences for how they want to work with a coach based on their personality, learning style, and previous experiences with coaching. For example, some clients may prefer a more direct coaching style, where the coach provides specific guidance and actionable steps to take. Other clients may prefer a more reflective coaching style, where the coach asks open-ended questions and encourages the client to explore their thoughts and feelings.
How do you work best?
Expectations: *
What are your expectations for coaching? This ensures that you are aligned with our approach and abilities as a coach.
How did you hear about Breakthroughs of North Florida?
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