Client Data Form

Client intake

Name

First Last

Date

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Occupation

Relationship Status

Married

Single, in a relationship

Single, not currently in a relationship

Divorced

Separated

Widowed

Children and ages (if any)

Emergency Contact

How did you hear about my coaching services?

What influenced your decision to work with a coach?

Have you ever been coached?

Yes

If so, please describe the experience.

Do you have specific goals for the coaching relationship?

What are your strengths?

What are your weaknesses?

What are you most passionate about?

What would your best life look like?

How would you describe yourself?

What stops you from having the life you want to have?

YOUR LIFE STORY: What is important for me to know about you?

Detail any important aspects, accomplishments, and highlights that you feel are important for me to know. I love to read, so feel free to write as much or as little as you’d like.

Please tell me as much as you want me to know about your spiritual journey and relationship with Christ.

LIFE BALANCE ASSESSMENT

Take a few minutes to think about your life and then rate yourself on the following scale with a score from 1 – 10, with 10 being completely satisfied, and 1 indicating plenty of room for improvement.

Physical Health