Sample "Client Intake Form - Michele Downey and Associates"

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XYZ Coach
Recovery Life Coach
Michele Downey and Associates
XYZ email
XYZ phone number
Client Intake Form
Client Name:
Date:
Date of Birth:
Phone Number/Email:
PAST COACHING:
Have you ever had any previous types of support such as other coaching, counseling,
pastoral counseling or therapy?
How long and what for?
How did it work for you and why did you enter…and why did you leave?
Scale of 0 to 10 (0 worst and 10 best) rate the experience.
GOALS:
What specifically would the perfect outcome look like when our coaching experience is
completed?
Why is this important to you?
Why do you believe these goals are right for you?
Have you ever seen or known anyone who has completed these goals?
What might stand in your way?
Who can help you achieve this goal? If anyone…
What have you been doing in a pro-active way to achieve your goals?
XYZ Coach
Recovery Life Coach
Michele Downey and Associates
XYZ email
XYZ phone number
Client Intake Form
Client Name:
Date:
Date of Birth:
Phone Number/Email:
PAST COACHING:
Have you ever had any previous types of support such as other coaching, counseling,
pastoral counseling or therapy?
How long and what for?
How did it work for you and why did you enter…and why did you leave?
Scale of 0 to 10 (0 worst and 10 best) rate the experience.
GOALS:
What specifically would the perfect outcome look like when our coaching experience is
completed?
Why is this important to you?
Why do you believe these goals are right for you?
Have you ever seen or known anyone who has completed these goals?
What might stand in your way?
Who can help you achieve this goal? If anyone…
What have you been doing in a pro-active way to achieve your goals?
How has that been working for you?
Where would you like to start?
When would you like to have this done by?
What is the payoff/what would you get if you meet your goals?
How can I best hold you accountable for your goals?
Are there any other important things I need to know about you that would be important
for our working together?
Do you have any questions of me at this time?
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