Carmine Media: Coaching Intake Form
I'm excited that you chose me to help you achieve your personal goals. Please complete the following information as completely as you can.
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Email *
Name *
Company Name
Address *
Business Type
Number of years employed in the business
Spouse/Partner Name
Children's Names
I would describe myself as: *
Others would describe me as: *
The three things that I like most about my life/situation are: *
If I could change three things about my life/situation, they would be: *
Some of my hobbies/interests are: *
The one thing I would like most to accomplish (but haven’t yet) is: *
The one thing I wish I could change in the short-term is: *
I think that the most important thing in life is: *
I am interested in working with a coach because *
List any specific goals you have for our coaching outcomes *
Why are you seeking coaching now? *
Invoicing and Terms
I am aware that the coaching relationship does not represent psychological counseling or any kind of therapy. I am also aware that coaching results can vary and are not guaranteed. I agree that I am entering into coaching with the understanding that I am responsible for my own decisions and results. I also agree to hold the Coach free from all liability for any actions or results for adverse situations created as a direct or indirect result of advice given by the Coach. *
I have read and understand the role of the coach and the client located here: *
Carmine Media will invoice the client $95 for each 50-minute coaching session. Payment is due within two weeks. *
Meetings will be scheduled using Google Meet. Carmine Media will contact the client at the agreed-upon time. If the Client fails to make the appointment time, the Client is still responsible for the coaching fee, unless 24-hour notice was given to reschedule the call. Carmine Media will make every effort to reschedule with the client. *
A copy of your responses will be emailed to the address you provided.
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