Surveypoint

Q1

Name:

Q2

Occupation:

Q3

Age:

Q4

Home Address:

Q5

Cell Phone:

Q6

Email Address:

Q7

Preferred Method of Communication

Q8

Okay to send texts &/or leave messages everywhere? If not, explain:

Q9

Emergency Contact (Include Full Name & Telephone Number)

Q10

Preferred Coaching Schedule (day of week; time of day)

Q11

How did you hear about my coaching services?

Q12

Have you ever had coaching before? If so, how was the experience?

Q13

What influenced your decision to work with a coach now?

Q14

What do you hope to gain from coaching?

Q15

Have you ever been diagnosed with a mental health condition? If so, what?

Q16

Are you currently seeing a therapist or counselor?

Q17

Is your faith a source of support that you would like to use in coaching?

Q18

Name 3 goals to accomplish in next 3 months:

Q19

Where do you want to focus first in your coaching?

Q20

What would make this coaching a success for you?

Q21

Client Intake -Form Fill

Name:

Occupation:

Age:

Home Address:

Cell Phone:

Email Address:

Preferred Method of Communication

Okay to send texts &/or leave messages everywhere? If not, explain:

Emergency Contact (Include Full Name & Telephone Number)

Preferred Coaching Schedule (day of week; time of day)

How did you hear about my coaching services?

Have you ever had coaching before? If so, how was the experience?

What influenced your decision to work with a coach now?

What do you hope to gain from coaching?

Have you ever been diagnosed with a mental health condition? If so, what?

Are you currently seeing a therapist or counselor?

Is your faith a source of support that you would like to use in coaching?

Name 3 goals to accomplish in next 3 months:

Where do you want to focus first in your coaching?

What would make this coaching a success for you?

Other information you may want me to know: