OptiMOM Coaching Initial Intake Form

These initial questions will give us a frame to build your work on. I encourage you to be as transparent with yourself and with me as you can. A lack of honesty will always reap a lack of satisfaction in your process. Your satisfaction will directly impact the lasting effects of our time and energy (and your money).

Full Name:

This is a required question

Date of Birth:

This is a required question

Email address:

This is a required question

Mailing address:

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Phone number you'll use for our calls:

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What are your preferred days and times for us to connect? Please provide at least 3.

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If you work outside the home, what is your occupation and do you enjoy your work?

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Are you a parent? If yes, please list your children (s) names and ages.

This is a required question

If you're a parent, do you currently like being a parent?

(no judgement, I promise...and your answers are confidential)

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How did you learn about OptiMOM Coaching?

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What is at least one thing you'd like to do more of in your life right now?

You can list more.

This is a required question

What is at least one thing you'd like to do less of in your life right now?

You can list more.

This is a required question

Are your currant lifestyle choices negatively effecting anyone in your life right now?

If yes, who?

This is a required question

The following questions are about how you have been feeling during the past four weeks. For each question, please select the one answer that comes the closest to the way you have been feeling, on a scale of 1 to 5:

1. None of the time 2. A little of the time 3. Some of the time 4. A good bit of the time 5. All of the time

How much of the time during the past four weeks have you felt calm and peaceful?

	1	2	3	4	5
						All of the time

This is a required question

How much of the time during the past four weeks did you have a lot of energy?

	1	2	3	4	5
						All of the time

This is a required question

How much of the time during the past four weeks have you been a happy person?

	1	2	3	4	5
						All of the time

This is a required question

How much of the time during the past four weeks did you take the time to relax and have fun daily?

	1	2	3	4	5
						All of the time

This is a required question

How much of the time during the past four weeks have you felt downhearted or blue?

	1	2	3	4	5
						All of the time

This is a required question

How much of the time during the past four weeks have you felt worthless, inadequate, or unimportant?

If you answer 3 or higher, I will ask you to complete a depression evaluation.

	1	2	3	4	5
						All of the time

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Listed below are some typical results experienced by coaching clients. Which 3 are most important to you?

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Do you already have specific goals you'd like to address in our work together?

If yes, please describe them.

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Please use this space to ask any questions or offer any additional information that you think would be helpful before we begin.

This is a required question

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