Coaching Client Intake Form - Young adult
"Getting to Know You"

Coaching is more effective and efficient if you can give me some information about yourself at the beginning. This is confidential information and you are free to answer only any questions you choose. I encourage you to be open as much as you are comfortable so that you can get the most out of the coaching relationship.

Name *
Preferred Name
Preferred Name
If applicable
Date of Birth *
Date of Birth
Address *
Phone *
(If applicable)
Life Satisfaction questionarre
How satisfied are you with different areas of your life Select a number from 1 to 10 next to each of the following areas of life. If you give an item a 1, you are completely dissatisfied with this part of your life. A 10 means that part of your life is going perfect and you could not be happier. Your overall satisfaction will change from day to day, but try to give an overall assessment of where you are at present.
Immediate Family
Degree of busyness and life balance
Housing, neighborhood, possessions, cars, etc.
Example: "I want to discover my gifts and passions and start a new career or life adventure."
Are you or have you ever been to counseling or therapy? *
1 being the lowest level of stress and 10 being the highest level of stress
What would you like me to do if you get behind in progress towards your goals?
What is your relationship with God? In what ways do you sense God might be challenging you, nudging you in a different direction or trying to get your attention?


Certified Life Coach and Daring Way™ Facilitator - Candidate
(703) 851-6332   |