0%
Worksheet

Coaching Client Intake Form

1. ➜

Your Name

Please enter your full name (Eg: Gina Marie Oades)

2. ➜

Email address

3. ➜

Phone number

4. ➜

Pronouns

5. ➜

What is your profession?

6. ➜

Do you enjoy your work? Why or Why not?

7. ➜

What other modalities or practices have you interacted with to help you reach your goals?

(Therapy, coaching, etc.)

8. ➜

What is your experience with meditation, yoga, breathwork or other somatic/embodiment practice?

9. ➜

In 1 to 3 words describe what you dislike the most about yourself?

10. ➜

In 1 to 3 words describe what you appreciate/like the most about yourself?

11. ➜

Have you received therapeutic treatment for any of the following: bi-polar/manic depression; post-traumatic stress; clinical depression; eating disorders; and/or suicide attempts?

12. ➜

Is there any aspect of your physical health that you would like me to know about?

13. ➜

Please let me know if you take any medication and/or are going through any sort of physical or mental treatment

14. ➜

Describe your relationship with your caregivers

For example, did you grow up with two or more parents, were they divorced, single parent, relative or non-relative caregiver.

Please also include how close your relationships were, favourite and least favourite memories.

Note: You can share as much or as little as you like here.

15. ➜

What are three things that you want to move through/release/transform in our time together?

16. ➜

What are three things you most want from our time together?

17. ➜

Please share your 3 biggest strengths in the areas of love, sex and relationships

18. ➜

What are the biggest challenges in your life right now in love, sex and relationships?

19. ➜

Do you have an intimate relationship (husband, wife, life partner, boyfriend, girlfriend, etc.)? If so, what is the quality of that relationship? What is great about it? What needs work?

20. ➜

What can I do that will make you feel safe and supported in our work together?

21. ➜

What are you afraid of about our work together?

22. ➜

Is there anything else you would like me to know?

powered by
Simplero