Client Intake Form_Free

NEW CLIENT INTAKE FORM

Career
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Email
example@example.com
Mobile Number

Area CodePhone Number
Home Number

Area CodePhone Number
Occupation
Employer
Marital Status
Names and Ages of Children:
LIFE SATISFACTION QUESTIONAIRE

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. A number 10 means "Completely Satisfied" A number 1 means "Dissatisfied". Try to give an overall assessment of where you are at present. Skip any question you do not feel comfortable answering.

FRIENDS/COLLEAGUES

	1	2	3	4	5	6	7	8	9	10

1 is Dissatisfied, 10 is Completely Satisfied

FAMILY

	1	2	3	4	5	6	7	8	9	10

1 is Dissatisfied, 10 is Completely Satisfied

HEALTH/FITNESS

	1	2	3	4	5	6	7	8	9	10

1 is Dissatisfied, 10 is Completely Satisfied

SELF IMAGE

	1	2	3	4	5	6	7	8	9	10

1 is Dissatisfied, 10 is Completely Satisfied

SLEEP

	1	2	3	4	5	6	7	8	9	10

1 is Dissatisfied, 10 is Completely Satisfied

CAREER

	1	2	3	4	5	6	7	8	9	10

1 is Dissatisfied, 10 is Completely Satisfied

My career is fulfilling and meaningful.

	1	2	3	4	5	6	7	8	9	10

1 is Dissatisfied, 10 is Completely Satisfied

I have a heathy balance between my work and personal life.

	1	2	3	4	5	6	7	8	9	10

1 is Dissatisfied, 10 is Completely Satisfied

My work brings out the very best in me, utilizing my strengths.

	1	2	3	4	5	6	7	8	9	10

1 is Dissatisfied, 10 is Completely Satisfied

I am willing to consider other career paths that more closely align with my interests.

	1	2	3	4	5	6	7	8	9	10

1 is Dissatisfied, 10 is Completely Satisfied

PERSONAL TIME

	1	2	3	4	5	6	7	8	9	10

1 is Dissatisfied, 10 is Completely Satisfied

BUDGET/FINANCES

	1	2	3	4	5	6	7	8	9	10

1 is Dissatisfied, 10 is Completely Satisfied

SOCIAL

	1	2	3	4	5	6	7	8	9	10

1 is Dissatisfied, 10 is Completely Satisfied

Spiritual Life

	1	2	3	4	5	6	7	8	9	10

1 is Dissatisfied, 10 is Completely Satisfied

GETTING TO KNOW YOU
Why do you want coaching? Examples: "I want more structure and balance in my life." "I have a vision to start a business." "I want to change jobs or careers." "I want to discover my faith/work relationship." "I like my company, but I want to change areas." What are YOUR ideal goals?
Are you or have you ever been in counseling or therapy?

YesNo
If yes, please explain.
Describe your career. What is most fulfilling? How are you utilizing your strengths? Do you look forward to going to work everyday? Are you satisfied with your salary? Are you open to new ideas or a new job or career? Do you ever feel you are being nudged in a different direction?
What are the most important things (good and bad) happening in your life right now?
In what ways would you like your life to be different one year from now? Be specific.
What is getting in the way of these goals?
(Optional) Do you believe in God? If so, how does God play a role in your life?
List at least three things you procrastinate at -- the things that you’ve been putting off.
What, if any, are your concerns about coaching?
Rate the level of stress in your life on a scale of 1 to 10. (1=low and 10=high)
What are your primary stressors?
How did you select me as your coach?
How do you like to be supported or held accountable?
What else would you like me to know about you?
Laura Lawrence Wilcock, CPLC | www.northstarlifecoaching.com | laura@northstarlifecoaching.com | (203) 655-0800
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