New Client Questionnaire

New Client Questionnaire
Name

First Name Last Name
Date

Month Day Year
Date
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Day Phone Number

Area Code Phone Number
Evening Phone Number

Area Code Phone Number
Fax Phone Number

Area Code Phone Number
Email
example@example.com
Briefly describe why you are interested in having life coaching. What goals would you like me to help you achieve?
Please rate the following areas of your life on a scale of 1 to 10, with 1 being very poor and 10 being excellent.
Physical Health
Emotional Health
Relationship (primary)
Friendships
Spiritual Health
Job or Career
Financial Prosperity
Sense of Purpose
Assertive Ability
Time Management
What else would you like me to know about you?
Are you in therapy or taking medication? If yes, please explain.

Life Coaching is also about life balance. The skills for creating what you want in one area of life will transfer to other areas. For each of the life areas below, write down what you would like to achieve as specifically as possible. Be as extensive as you’d like.
Professional Goals:
Financial Goals:
Physical (Health) Goals:
Relationship Goals
Emotional Goals:
Spiritual Goals:
In the past, what has helped you achieve goals you've set?
What are a few of your strengths?
What additional skills do you need to achieve your goals?

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