First Name*

Last Name*

Do you have a nickname that you’d rather me use?

Your Pronouns

Email*

Phone Number*

Would you agree to receiving text communications from me, at the phone number you provided above?*

Yes

Address*

Emergency Contact Name*

Who do you live with (e.g., spouse, children, partner, roommate)?*

Name 3-5 things you did as a kid that you loved and did well.*

Name 3-5 things you’ve done as an adult and really enjoyed.*

If you were to fully live your life, what’s the first change you would start to make?*

What are you not willing to put up with anymore?*

What is your greatest fear?*

Name 3 specific things you hope to gain from this coaching engagement.*

How important are each of those things to you (on a scale of 1 to 10)?*

Who is on your “team” (i.e., your support network), and which of them is local to you? *

How do you take care of yourself (e.g., your rest time, leisure activities, any form of exercise/movement, meditation)? *

Who can I thank for referring you? Or how did you find out about my services?

Client Intake Form

Please take a moment to respond to the following questions to the best of your ability, prior to our first meeting. Thank you!

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