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Intake form
Intake for first time clients (all information is kept strictly confidential)
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Name
Your answer
What is your email and phone number?
Your answer
Why are you coming to coaching? What results would you like to see?
Your answer
The next section is about your self-care. It helps me, as your coach, to guide you in goal setting and support you to achieve a balanced life.
What is your overall self-care like?
Excellent, I feel balanced and steady
Good enough, I occasionally struggle but overall okay
Okay, but some of the time I struggle to maintain self-care
Not great, I often struggle to balance my self-care
Poor, i often have issues with putting my self-care first
Clear selection
What is your sleep like?
Excellent, I regularly sleep deeply and well
Good enough, with occasional struggles
Okay but some of the time I struggle with sleep
Not great, I often struggle with sleep
Poor, I often don't sleep well and it impacts my self-care
Clear selection
How is your relationship with food? Do you frequently eat good, healthy food and feel balanced? Or do you struggle sometimes or often with over or under eating?
Your answer
Do you have mindfulness practices, such as breathing deeply, meditation, journalling, yoga, qi gong, walking in nature or any other practice that you use regularly to guide you?
Your answer
How often do you drink alcohol or take other substances recreationally?
Frequently 3-5x week
Sometimes 2-4 x week
Occasionally 1x a week or less
Rarely, 1x month or less
Never
Clear selection
Do you have any mental health issues or trauma that would be helpful for me to know about? If so, have you seen a counsellor, therapist or other health care provider to explore the impact on your life?
Your answer
What are your top three worries, fears or anxieties in life?
Your answer
What are your top three passions or joys in your life?
Your answer
Is there anything else you'd like me to know as your coach that might influence or impact our coaching sessions?
Your answer
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