Name ___________________________________    Date _________________

Phone ________________________________

Occupation ________________________   Education ___________________

Marital Status _______ Children ____________________________________

Members of your current household (their relation to you)


Hobbies _________________________________________________________________________________________________



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 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.