Confidential Client Intake Questionnaire

Confidential Client Intake Questionnaire

Full Name *

Address

City

State

Postal code

Email *

Phone *

Occupation

Date of birth *

City of Birth *

Time of Birth *

Names/ages of Children:

Preferred Language:

Emergency Contact Person & Phone:

Overall Health:

Previous/Current Coaching (why, when, how long):

Previous/Current Psychological Treatment (why, when, how long):

Medications currently taking:

Areas of Self-Actualization Tool

Instructions

This tool is to support you to reflect on where you would like to be in specific areas and where you currently are. Please be honest with yourself, this isn’t an assessment. We will use the tool as a starting point for reflecting and creating the coaching outcome together.

For each of the below areas, think about what an ideal life would look like for you. Then rate out of 10, how satisfied you currently feel in this area.

1 = very dissatisfied, whereas 10 = fully satisfied.

Use the first number (score) that pops into your head, not what you think it should be.

To support you to rate your satisfaction in each area, we have given you some examples of what a fulfilled life might look like in each area. However, please don’t limit yourself to these examples and instead focus on what is important to you in that area.

Love and Relationships Rating 1 - 10

For example, you’re in a fulfilling romantic relationship, where you feel ‘met’ on all levels, you have fulfilling, rich, growth-oriented relationships with spouse, family, and friends.

Prosperity/Career Rating 1 - 10

For example, you’re earning enough to have the resources to thrive, prosper and contribute in life, you’re managing finances effectively, and working in a career where you feel fulfilled and aligned with your values.

Creativity Rating 1 - 10

For example, you enjoy creating, playing, and having fun on a regular basis, you have some form of creative expressions, such as painting, dancing, writing, etc.

Spirituality Rating 1 - 10

For example, you feel deeply connected to a higher power and trust life to support you to create, grow and evolve, you trust your inner wisdom to guide and support you.

Health Rating 1 - 10

For example, you’re fit, healthy, radiant, vital, and have enough energy to do everything you want to do, you support yourself to eat well and stay calm/centered daily.

Influence Rating 1 - 10

For example, you feel like you’re impacting, uplifting, and empowering regularly, you’re leading the groups and numbers of people you want to be impacting.

Calling Rating 1 - 10

For example, you feel like you know what you’re calling or purpose is, you’re cultivating your purpose and sharing it with the world.

Confidence Rating 1 - 10

For example, you feel the confidence to create what you want in your life, to lead others, to take risks, express yourself fully with others, and follow your inner wisdom/ideas.

From the above areas, which area of your life represents the biggest gap between what you deeply desire and how your life is currently showing up?

Reflection Questions

The following questions are designed to help me get to know you better, as well as understand a bit more about what you would like to receive from the coaching relationship. They are designed to be pondered and to stimulate your thinking in a way that will make our work together dynamic and rich. I suggest you reflect on the questions for a few days before you compose your responses.

Please send me your responses at the latest 24 hours before the first coaching session.

What is it you most want to create in your life right now? What would success look like?

Which areas in your life and/or work do you most want to impact through coaching?

What have been the biggest challenges that have been affecting your life?

List 5 qualities you appreciate most about yourself and 5 things about yourself that you struggle with:

Think about two people that you really admire. What inspires you about them?

What activities do you most enjoy doing?

What would you most like to receive from me, as your coach? How can I best support you in this coaching relationship?

Is there any other background information that would be relevant for me to know? e.g. work, health or relationships, etc.

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Thank you for taking the time to complete this questionnaire. I look forward to working with you!