Coaching & training intake form
• Everything you write is confidential.
• You'll get an email after with your responses.
• After you submit this, I'll email you to set up a free phone call. You can also email me at
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Email *
First & last name *
(she/her, they/them, etc) Read more about gender pronouns here:
Title & organization
(If applicable)
Phone *
What would you like me to know about you? *
(and/or your organization)
How did you hear about me? *
Specifically where or from whom?
I am interested in (or signed up for): *
What would you love to achieve through working together? *
Feel free to include specific results or measurable goals, broad intentions (i.e. being a more empowering manager), or growth objectives (mindsets, skill areas, habits, etc).
Where are you now in relation to these objectives? *
What is working or not working currently? Where might there be an opportunity for learning, growth, or breakthrough?
What are you looking for in your coach / trainer? *
What would you LOVE to be present in the person you choose to work with? i.e. "I'm looking for someone who... (has certain qualities, takes a particular approach, has a specific area of experience, really "gets" a particular context, etc)"
Did you review my packages & pricing? *
What's your budget for working together? *
Include A) a specific monthly budget (i.e. "$800/month"), or B) a total amount over a specific period of time (i.e. "$6,000 for the remainder of this year").
Any questions about me or my approach? Anything else you'd like to say?
You can read more here:
4. IDENTITY (optional)
100% confidential + 100% optional. Your answers help me assess how well I'm serving a diverse & inclusive community. They WON'T influence whether or not I see us as a fit in any way.
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Race / ethnicity
East Asian includes Chinese, Japanese, Korean, Mongolian, Tibetan, and Taiwanese. South Asian includes Bangladeshi, Bhutanese, Indian, Nepali, Pakistani, and Sri Lankan. Southeast Asian includes Burmese, Cambodian, Filipino, Hmong, Indonesian, Laotian, Malaysian, Mien, Singaporean, Thai, and Vietnamese.
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Clear selection
Sexual Orientation
Clear selection
Would you like to elaborate on any of the questions above, and are there additional identities that are important to you?
If so, please describe here. Thank you!
A copy of your responses will be emailed to the address you provided.
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