New Client Intake Form
Name
Your answer
Email
Your answer
Date of birth
MM
/
DD
/
YYYY
Sex
Your answer
Marital status
Your answer
Occupation
Your answer
Education
Your answer
How did you hear about Real Time Life Coaching?
Your answer
Have you participated in coaching or therapy before?
Your answer
What do you hope to gain from life-coaching?
Your answer
Please rate the following aspects of your life
On a scale of 1-5, with five being the highest, please insert the number that represents how you would describe yourself.
I am optimistic
I am satisfied with my life
I am satisfied with my financial situation
I am satisfied with my social life
I feel good about my personal relationships
I am satisfied with my health
On a scale of 1-5. with five being the highest, please rate your current relationships. How good is your relationship with your:
Partner
Children
Siblings
Friends
Colleagues
Boss or teacher
Tell your coach a little bit about yourself.
What is the most important thing that I should know about you right now?
Your answer
Write down your three most significant accomplishments:
Your answer
What are your three most significant disappointments?
Your answer
Describe your top three strengths:
Your answer
Describe your most aggravating weakness:
Your answer
I feel lowest when:
Your answer
What is your relationship with your parents like?
Your answer
People like you because you are:
Your answer
Describe any goals or desires that you have yet to fulfill:
Your answer
What has stopped you from achieving these goals or desires?
Your answer
Crisis Information
Do you regularly use alcohol or engage in recreational drug use?
Your answer
In the last year, have you experienced any significant life changes or increased stress?
Your answer
Have you had suicidal thoughts in the past or recently? If yes, please explain:
Your answer
Have you ever or are you currently involved in self-harming behavior? If yes, please explain:
Your answer
Do you have any current homicidal thoughts? If yes, explain:
Your answer
Are you currently taking any psychiatric medication? If yes, which kind?
Your answer
Confidentiality:
RTLC takes your privacy very seriously and your personal coach will not share this information with anybody else without your written consent. All information exchanged during your future sessions will remain confidential. Your file will be stored on an external hard drive and will not be connected to your name.

Publication: 
All coaching services delivered by your coach such as the application of coaching methods, exercises and tools may not be commercially published, or shared with others without written consent of the organization. 

Audio and Videotaping: 
Your RTLC coach will not record your sessions without your consent and you may not record your coach unless she agrees. If both parties decide that having a record of the coaching sessions is of benefit, the confidentiality and the publication agreement, applies to the recordings as well. 

I am looking forward to our first session.

Your Coach,
Ady Sheerer.

By submitting this form I agree to the terms and conditions listed above.
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