Client History Form

All client information is private and secure. This information is needed to insure we are a good fit.

Today's Date

YYYY

Name

First Name

Last Name

I am currently interested in:

Date of Birth

YYYY

Age

Phone

(###)

###

####

Is it okay to leave messages at the phone number above?

If no, please specify

Address

Is it okay to leave personal coaching information in body of email?

If no, please specify

Occupation

Name of Business

How long at this employment

Are you happy at this employment? If not, please tell me briefly what you would change about it

Emergency Contact - Name / Phone

Names, ages and relationships of other significant people in your life

(ex: spouse, children, parents, friends)

Pets

Name and Breed

Education History

Health Status

Do you have difficulty with sleep? If so, please briefly tell me why

Do you have any history or current use of drugs or alcohol? If yes, please describe

Are you seeing a therapist at this time? If so, please briefly describe the reason for seeing a therapist.

Do you take any medications, if yes, what

Do you exercise regularly? If so, what type

What do you enjoy doing in your free time?

What is your favorite movie and why?

What’s your favorite song and why?

If money were not a factor, what would you do if you knew you could not fail

Do you have a personal relationship with Jesus Christ?

Do you currently attend a place of worship? If so, where

What is one specific area of your life that you feel needs special attention, briefly tell me a little about that

Is there anything you would like me to know about you or your circumstances before we begin?

How did you hear about my coaching services?

What influenced your decision to work with a transformational life coach?

Have you ever been coached before? If yes, please describe your experience