Client Intake Package | The Next Level Professional Coaching

Full Name *

Prefix First Name Last Name

E-mail *

Address *

Street Address
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City	State / Province
Postal / Zip Code	Country

Phone Number *

- Area Code Phone Number

Birth Date

Month Day Year

Take some quality time to complete this information form. Some questions you’ll find easy to answer and others will cause you to stop and think. This information will be equally valuable for both of us in creating your coaching plan.

What are your current top three goals?

Goal 1 *

Goal 2 *

Goal 3 *

Have you worked with a coach before or a similar one-on-one adult relationship (e.g. tennis coach, piano teacher, therapist)? If yes, what worked well for you and what did not work in the relationship(s)?

What are the three biggest changes you want to make in your life over the next 3 years?

Change #1

Change #2

Change #3

What are you most wanting to achive? And do you feel ready for it?

What would you say have been your 3 greatest accomplishments to date?

Accomplishment #1

Accomplishmentt #2

Accomplishment #3

Looking at the last 6 months of your life, do you like the direction your life is moving in?

What major transitions have you had in the past two years? Entering or approaching a new decade, a new relationship, a new job, a new role, a new residence, change in children’s ages/stages, etc.?

Improvements

List improvements you would like to make in the following areas of your life.

Family / Home life

Financial situation

Career or Business life

Personal Character

Relationships

Is your life one of your choosing? If not, which parts are being chosen for you?

Self Care

Learning

Leisure time

What are your primary stressors?

List five things that you are tolerating or putting up with in your life at present. (examples: info. you can’t find, clutter, rude friends, poor lighting, tight shoes, dented car, job dissatisfaction, dead plants, broken equipments, old appliances, etc.)

On a scale of 1 to 10 , with 10 being the highest, rate the amount of stress in your life right now.

Your Life

On a scale of 1 to 10 with 10 high, rate the quality of your life today.

Who are the key people in your life and what do they provide for you?

What is your favorite part of your typical day?

What is your least favorite part of your typical day?

List 5 adjectives that describe you at your best.

List 5 adjectives that describe you at your worst.

What are your 3 major concerns / fears about yourself?

What are your 3 major concerns / fears about life?

What would you like me to do if you get behind on your goals?

How will you know when you are recieving value (i.e. your money's worth) from the coaching process?

Do you understand that if you miss a coaching session without notice, I will be unable to make it up?

What types of approaches discourage you or take away inspiration?

Are there any alterations in my natural style you wish to make when working with you?

Do you enjoy self - assessments and improvement programs?

Here are ways coaching clients work with me. Which appeal to you?

Brain storming strategies together.

Support encouragement, validation.

Insight into who you are and your potential.

Painting a vision of what you can become or accomplish.

Exploring and removing obstacals.

Accountability, checking up on your goals.

Working through self-improvement programs together.

Suggesting or designing action steps.

Do you have a personal or professional vision? If so, what is it?

What is a dream or goal you have given up on?

What part of yourself, if any, have you given up on?

If you reach the age of 95 and continue to live your life the way you are right now, what regrets do you think you will have? (tip: complete the statement "I wish I had…") Do not include things from the past–only things you will regret if you continue your exact present path.

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The Next Level Professional Coaching

Client Intake Form