Recovery Coaching Intake Form

As your coach, it is important for me to understand who you are, what you value, and how you approach life. Please set aside some time to thoroughly complete this online form prior to our initial session. After you complete this online form and click the Submit button, the information will be sent to me via email. What information will be transmitted? The information that you entered will be transmitted to me via email. In addition, the system will transmit your IP address of your computer, and the date and time that you submitted the information will be sent to me. Thanks and I look forward to meeting with you.

General Information

Name *

First

Last

Date of Birth: MM/DD/YYYY *

Email *

Is it okay to send you email at this email address? *

Phone Number *

Is it okay to leave a message/voicemail at the phone number you listed? *

How did you hear about us? *

Are you in a committed relationships? *

If you're currently in a committed relationship, how long have you been in the relationship? *

Are there any current life transitions that I should be aware of? *

Outside of work hours (during your personal time), how much time do you spend on the computer/Internet per week? *

Goals

What are the primary short-term goals that you want to focus on for the next ninety days? *

What long-term goals do you want to focus on in our coaching? (Only choose things that you really want, not what you feel you should do! Also, the short-term goals should support your long-term goals. You should anticipate that long-term goals, as the name suggests, will likely take longer than 90 days to achieve and maintain. *

Why have you hired me? In other words, what about me, what I offer, my experience, or my style, really works for you? What did you hear that made you pursue coaching, and coaching with me? *

Helpful Information

What do you consider to be your personal and/or professional strengths? (E.g. hard working, organized, good with computers, good communicator, good at building relationships and networking with others, etc.) ? *

What do you consider to be your growth areas? (E.g. poor follow-through, I have to be in control/ in charge at all times, difficulty in working with others, etc.) ? *

What are five aspects of your personal/professional life, past or present, of which you are most proud? *

Are you aware of any behaviors or beliefs that stand in the way of you enjoying your life or achieving your goals? If so, what are they? *

How will you know that our coaching has been effective? *

What would you like to do or accomplish during your lifetime (personally or professionally), in order to consider your life well lived, with few or no regrets? *

What is your passion in life, or what makes you happiest and most fulfilled? *

What are your favorite pastimes—things you enjoy doing for fun (name at least 5 if possible)? *

What motivates you or gives you energy to complete big or challenging goals? (E.g. deadlines, consequences, caffeine, your values, meditation, exercise, being out in nature, status / prestige, etc.) *

What three things in your life are causing you discomfort/stress? *

Tell me what I should know about you in order to coach you best. *

Submit