COACHING INTAKE FORM Name * First Name Last Name Date of Birth * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * (###) ### #### Preferred Communication Method: * Phone Text Email Background Information Occupation: * Medical History: * Do you have any health condition that you would like to share? Are you currently taking any medications or supplements? * If yes, please list below Prakriti (Ayurvedic Dosha) Quiz Body Type: * Thin or Light (Vata) Medium or Athletic (Pitta) Heavy or Solid (Kapha) Skin Type: * Dry (Vata) Sensitive or Easily Reddened (Pitta) Oily (Kapha) Appetite: * Irregular (Vata) Strong, Consistent (Pitta) Steady but Slow (Kapha) Sleep Patterns: * Light, Interrupted (Vata) Moderate, with Occasional Disturbances (Pitta) Heavy, Deep (Kapha) Mental Characteristics: * Creative, Quick Thinker (Vata) Focused, Strong-Willed (Pitta) Calm, Easygoing (Kapha) Emotional Characteristics: * Anxious, Fearful (Vata) Aggressive, Irritable (Pitta) Complacent, Indifferent (Kapha) Digestion: * Gas, Bloating (Vata) Acid Reflux, Heartburn (Pitta) Slow, Heavy Feeling (Kapha) Coaching Goals & Expectations What are your primary reasons for seeking life coaching? * Describe your top 3 goals you'd like to achieve through coaching: * What has been preventing you from achieving these goals so far? * What does success look like to you at the end of our coaching relationship? * Personal Strengths & Challenges List your top 3 strengths that could help in reaching your goals. * What are your biggest challenges or obstacles currently? * On a scale of 1 to 10, how committed are you to achieving your goals? (1 - Not committed, 10 - Fully committed): * Previous Coaching/Counseling Experience Have you worked with a coach or counselor before? * Yes No If yes, what was helpful or unhelpful about that experience? Logistics & Preferences Preferred Session Frequency: * Weekly Bi-weekly Monthly Preferred Session Length: * 30 minutes 45 minutes 60 minutes Best Days/Times for Sessions: * Do you have any preferences or special requirements for our sessions? * Suitability for Coaching Screening Do you currently have any of the following thoughts or feelings? Suicidal Ideation: * Yes No Self-Harm: * Yes No Harm to Others: * Yes No Deep Depression: * Yes No Severe Anxiety or Panic Attacks: * Yes No Substance Abuse Issues: * Yes No If you answered "Yes" to any of the above, please explain (Optional): Additional Information Is there anything else you'd like me to know before we start working together? How did you hear about our coaching services? * Thank you!
