Client Information Form

Today’s Date: Date of Birth (DD/MM/YYYY): Name: Age: Gender: Race/Ethnicity: Email Address: Mailing Address: Physical Address: Country: City: State: Zip: Type of Residence: Emergency Contact Name: Phone: Email: May we leave a message? Best number to leave a message and contact you: Number for text for appointment confirmations: Reason for Visit: Areas of your life you want coaching (Check all that apply):

Occupational Information

Employment Status: Current employer: Phone: Your current Position: Commencement Date:

Relationship Information

Describe your relationship status:

Coaching Needs

Please complete as much of this prior to your 1st session. Whatever you don’t complete we will address in your initial session.

What 3 specific goals do you want to achieve in the next three months? What are the three biggest changes you want to make in your life over the next three years? What is your main goal for our coaching sessions? What would you say have been your three greatest accomplishments in your life to date? What is the hardest thing you have had to overcome? Who are, or have been, your major role models? What major transitions have you had in the past two years? Is your life one of your choosing? If not, which parts are being chosen for you? List 5 things that you are tolerating or putting up with in your life at present which you are dissatisfied with: What would you expect or like your coach to do if you get behind on your goals?

Client Information Form

Occupational Information

Relationship Information

Coaching Needs

Electronic Signature