Client Intake Form

Name*
First Last
Date
Phone
Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth*
Why do you want to work with a coach?*
How will you know when you get what you want? What will specifically change?*
What is your personality like? How do you like to be coached?*
List your top 3 desired life goals you seek to achieve. Connect to purpose.*
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List your top 5 “Waste of Time” items: Energy drainers, excuses etc.*
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What area in your life needs greater balance? Explain.*
What is non-negotiable? (ex. Relocating for work)*
What are you most passionate about right now?*
List the top 3 desired outcomes you want at the end of your coaching program (be specific).*
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Core Values Assessment
This exercise is to help you prioritize your most important values right now and to see where there may be discrepancies in how you live them out.
1. From the list at the bottom of this page, choose 10 values that you hold most strongly. You can write-in values that are not listed.*
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In Column 1, write your top 10 values in order of importance (1=Most, 10=Least). In Column 2, rank them by how they actually show up in your life (for example, if you ranked Health/Fitness as #1 in importance but you do not exercise and have a poor diet, you would rank this value as #10 in Column 2.*
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Column 1 Column 2
Areas of Balance
On a scale of 1 to 10 with 10 being highly satisfied, rank your level of satisfaction in each area:
Career:*
Please enter a number from 1 to 10.
Financial:*
Please enter a number from 1 to 10.
Physical:*
Please enter a number from 1 to 10.
Confidence:*
Please enter a number from 1 to 10.
Relationship:*
Please enter a number from 1 to 10.
Social:*
Please enter a number from 1 to 10.
Mental/Emotional:*
Please enter a number from 1 to 10.
Work/life balance:*
Please enter a number from 1 to 10.
Email
This field is for validation purposes and should be left unchanged.

Core Values:

achievement
advancement
adventure
affection
balance
beauty
children
commitment
communication
competition
cooperation
creativity
economic security
education
empowerment
excellence
fame
family
freedom
friendship
fun
God
happiness

health/fitness
helpfulness
honesty
independence
inner harmony
integrity
intimacy
involvement
job/career
learning
leisure
liberty
love
loyalty
marriage
money
nature
order
peace
pleasure
power
purpose
recognition

responsibility
romance
security
self-confidence
self-expression
self-involvement
self-respect
solitude
spiritualiy
trust
truth
unity
valor
variety
wealth
wholeness
wisdom

Column 1	Column 2

Client Intake Form

Core Values Assessment

Areas of Balance

Core Values: