Client Intake Form Step 1 of 4 0% These questions will enable me to help you get the very best results from my coaching program. Understanding your personal history, goals, and motivators is the first step in the process as it helps you reflect deeper into your personal and business goals and establishes a starting point for our time together.PERSONAL INFORMATIONName* First Last Email* Cell PhoneAlternate PhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Birth Date MM DD YYYY Marital StatusSingleMarriedCommitted RelationshipWidowedDivorced# of Children & AgesHighest Education Level High School Bachelors Graduate School Professional Certification/License OccupationEmployerEmergency Contact First Last Emergency Contact Email Emergency Contact PhoneWhat type of coaching do you need?*Life/Personal CoachingBusiness CoachingBoth Save and Continue Later WHO AM IWhat key business/life changes do I want to achieve from this coaching?What are the 3 biggest changes I want to make in my business/life?What do I want in my business/life? What do I wish to create?My business is:If anything was possible, I would wish for:On a scale of 1 - 10, how happy am I with my life right now? What is making me happy?On a scale of 1-10, how motivated am I in my work/personal life? What motivates me?On a scale of 1-10, how stressed do I feel right now? What are my key stressors?What has been my 3 greatest successes to date?What is the greatest challenge I have had to overcome?How do I overcome challenges or difficulties in my life?What are the major transitions I have had in the past two years?Where am I stuck?What is most important to me in my life and why?What in my life - business or personal - is not fitting into who I am?How will I know when I am receiving value from the coaching process?I would like to achieve the following from my coach during coaching sessions: (Check all that apply) Gaining clarity of issues Understanding what is important/what motivates me Exploring and understanding what is holding me back Gaining an insight into who I am, my strengths, capabilities, and potential Providing encouragement and support Helping define goals Helping to identify actions and next steps Challenging me with difficult questions Providing honest and direct feedback Making me accountable for my goals Save and Continue Later What are my strengths and greatest attributes?What do I always find time for?Who are the most important people in my life and what do they provide me with?Who and what do I value most in life and my business?What will I regret not doing, having or becoming in my life?My life exactly as I want it to be in one year from now is: (write in the present (I AM) and only use positive phrases). This should be several paragraphs and include personal, career/business and relationships. Save and Continue Later BUSINESS COACHINGMy current revenue/income is:My revenue/income goals as I want it to be in one year from now is:EmailThis field is for validation purposes and should be left unchanged. Save and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms.