Client Exploration Application
Intake Form - Everything you share here is private and confidential. Please share openly and freely.
Name (first and last) *
Your answer
Phone Number *
Your answer
E-mail *
Your answer
Address (at least country you reside in) *
Your answer
website(s)
Your answer
Birthday (include time and location if you know it) *
Your answer
Have you worked with a coach before? If yes, why? *
Your answer
Why are you drawn to work with me as a coach for you? *
Your answer
how do you currently answer the question 'what do you do?' Does that feel aligned for you? *
Your answer
Where do you see yourself personally and professionally 3 years from now? *
Your answer
What are you most challenged with right now? What do you desire support with most? Please be as clear as possible here. *
Your answer
If there was just one powerful thing you could get out of our time together, what would that be? Again, please be as specific as possible (for example, if clarity is your answer, I'd like to know what specific clarity you'd walk away with). *
Your answer
What are your Top 1-3 goals this year, in order of relevance? *
Your answer
Do you have any questions for me?
Your answer
Agreement: {If we are to work together}*PERSONAL RESPONSIBILITY AND RELEASE OF BUSINESS AND HEALTH CARE RELATED CLAIMS* The Client acknowledges that the Client takes full responsibility for the Client’s business, life and well-being, and all decisions made during and after the time he/she woks with the Coach. All recommendations or advice are recommendations only, and at all times the Client has the choice to disregard recommendations. The Client releases the Coach, his/her heirs, executors, administrators and assigns, its officers, directors, shareholders, employees, teachers, lecturers, agents, coaches and staff (collectively, the Releasees) from any and all liability, damages, causes of action, allegations, suits, sums of money, claims and demands whatsoever, in law, admiralty or equity, which against the Releasees, the Client ever had, now has or will have in the future against the Releasees, arising from the Client’s past or future participation in, or otherwise with respect to, the coaching relationship. If the terms of this Agreement are acceptable, please mark "I Agree" below, to signify acceptance. By doing so, you acknowledge that: (I) the above is meant to have legal significance and is regarded as legally binding and, (II) you understand, accept and agree to abide by the terms hereof. *
Today's Date *
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Signature (write first and last name again) *
Your answer
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