Coaching Intake Form

Date(Required)

Name(Required)

First Last

Email(Required)

On a scale of 1 to 10, rate your life in the following areas (1 being the least satisfying and 10 being the most satisfying ):

SELF(Required)

Health/ Fitness

Learning/ Education

Spirituality/ Purpose

Productivity/ Performance

RELATIONSHIP(Required)

Intimate Relationship

Family

Friends/ Community

DEVELOPMENT(Required)

Career/ Business

Money/ Wealth

Hobbies/ Fun

Area 1 [specify which one from the list above]:

What would a “10” look like?

What is my current situation?

Area 2 [specify which one from the list above]:

What would a “10” look like?

What is my current situation?

Area 3 [specify which one from the list above]:

What would a “10” look like?

What is my current situation?

What approach inspires or motivates you?

What approach discourages or demotivates you?

Anything else you would like to share?

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