CLIENT INTAKE WORKSHEET
Name ___________________________________ Date _________________
Phone ________________________________
Occupation ________________________ Education ___________________
Marital Status _______ Children ____________________________________
Members of your current household (their relation to you)
_______________________________________________________________
Hobbies _________________________________________________________________________________________________
MEDICAL HISTORY
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?
COACHING AGENDA
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 Signature
_____________________________________
Client acknowledges that he/she understands this questionnaire and that all information provided is complete and accurate to the best of his/her knowledge.