Lasers Consulting and Coaching Intake Form - Coaching Clients
The issue of confidentiality is paramount to this relationship. My understanding is that nothing in this
relationship is to be discussed outside of our conversations. There are times when references to others
may be helpful however, I would not ever mention a name or person that would lead someone to infer
the discussion was about you as a client. The contents of this form will be kept confidential.

In completing this form, there is no right or wrong answer; just answer truthfully and from the heart.
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First Name *
Last Name *
Gender *
Date of Birth *
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Address *
City *
State *
Zip Code *
Email *
Telephone *
How many coaching sessions would you like to schedule? Sessions are scheduled one time per week. An electronic invoice will be sent to the email address you provided based off your selection after your intake form is reviewed.  A scheduling email will also be sent to you after your intake form is reviewed. *
What trauma or traumas are you seeking support? *
Please note any issues that are important for me to understand better as a client (e.g., physical, psychological, belief issues, medications). *
What do you want to change or improve now? *
How will you know when you have achieved what you want? *
What is holding you back? (i.e., unhealthy relationships, recurring problems, limiting beliefs, unproductive habits, disorganization, etc.) *
What is most important to you in your life and how do you know that? *
What are your major concerns and why? *
What in your current situation upsets you the most?  Why do those things upset you? *
Who is the person or persons that are currently in your support system? *
List your top 5 values *
What is your personal vision? *
In twenty-five words or less, write what you believe to be your personal purpose/mission in life. *
What are your primary business/professional goals? *
What are your professional strengths and assets? *
List two goals you have currently (Now Vision): *
List two goals you want to accomplish within the next 12 months (Near Vision): *
List five goals you want to accomplish in your lifetime (Far Vision): *
What are you willing to do to achieve your goals? *
What accomplishments are you most proud of in your life and why? *
What do you most want to get out of our session? *
How would you know if you are getting it? *
Please sign this document by typing your name and dating this form attesting that the information you have written on this form is accurate to best of your knowledge. *
Type your first and last name *
Date *
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