CLIENT INTAKE WORKSHEET
Name ___________________________________ Date _________________
Occupation ________________________ Education ___________________
Marital Status _______ Children ____________________________________
Members of your current household (their relation to you)
Have you been under treatment (physical or psychological) in the past year? ______
Have you ever been treated for an emotional problem? _______
Are you currently receiving treatment or counseling? _________
Are you presently taking any medication? ______________
Any suicidal thoughts, feelings or actions? _____________
Any homicidal or assaultive thoughts or feelings or anger control problems? ________
Any problems with (underline all that apply): eating, sleeping, chronic pain, heart, diabetes, epilepsy, recent weight changes, fears/phobias?
What are the 5 most important things in your life?
What would you like to explore in coaching?
What are some changes you’d like to make in your life, if you had the support to do it well?
What would you like to achieve in your life and career over the next three months?
Client acknowledges that he/she understands this questionnaire and that all information provided is complete and accurate to the best of his/her knowledge.