Coaching Intake Form

The coaching experience can be extremely empowering and life-changing (that's why I do what I do). To guide our work together, I have a series of questions for you to answer. Your ability to answer them clearly and thoughtfully will serve us both (win-win, my friend!). You may find they help you clarify perceptions about yourself and where you wish to devote your resources. Some questions are “pondering-type” questions, designed to stimulate your thinking and perceptions in a way that will strengthen our work together. Other questions are more fact-based and will help me determine if/when/how to refer you to appropriate medical, psychological, nutritional, or other related services.

I appreciate your willingness to share yourself with me and look forward to getting to know you. Please set aside quiet time to answer these questions (maybe throw on some tunes to get you in the mood for a big, ol’ party for one). Also, please take your time answering them (we can’t rush genius). Your answers will be treated with complete confidentiality.

 

Please complete the form below

PROFILE
Name *
Name
Relationship Status
COACHING PRIORITIES
I want to address the following areas in coaching (please check no more than five total):
Vitality
Connection
Meaning
PERSONAL APPRAISAL
As your coach, it’s important for me to understand how you view yourself, your life, and the world. Each person is unique, and understanding your challenges and aspirations will help me support you. As your coach, my job is not to “treat” you, but to be your ally, your guide, your yeasayer, and your resource. When appropriate, I will refer you to medical, psychological, nutritional, and other related services.
VITALITY
Stress: I am able to cope with my current stress load.
Mark any symptoms that apply to you.
During the past 4 weeks, to what extent have you accomplished less than you would like in your life, as a result of emotional issues (e.g., feeling depressed or anxious)?
Sleep: I get 7-8 hours of uninterrupted sleep every night.
Energy: I have a zest for life and energy throughout the day.
Mindset: I am aware of my thoughts and actions and typically feel nonjudgmental towards myself.
Nutrition: My diet is exactly where I want it.
Physical Fitness: I feel strong, flexible, and in shape. I am happy with my physical condition.
Recommended physical activity guidelines include: A. Resistance: Moderate- or high-intensity muscle strengthening/endurance/agility activities that involve all major muscle groups 2+ days/week B. Flexibility: Static or dynamic stretching of all major muscle tendon groups (4+ repetitions/group) 2+ days/week C. Cardiorespiratory: At least 20 minutes of vigorous aerobic activity 3+ days/week (hard enough to make you breath heavily or make your heart beat faster) OR 30 minutes of moderately intense aerobic activity 5+ days/week
Body Image: When I look in the mirror, I feel content and grateful for the body I have.
Alcohol (or other substance): I have a healthy relationship to alcohol/substance use.
Tobacco
Mark the appropriate response.
Finances: The amount of money I have gives me feelings of security and freedom.
My readiness to make changes or improvements in my vitality:
On a scale of 1-10 (1 = lowest; 10 = highest), the importance to me of having a high level of vitality is:
On a scale of 1-10 (1 = lowest; 10 = highest), my confidence level in my ability to reach and sustain a high level of vitality is:
CONNECTION
Relationship/ Romance: I am fulfilled by my current relationship status.
Friends: I have people in my life whom I trust with my problems, care about, have fun with, and can be myself around.
Family: I love and respect my family, and I know they love and respect me.
Physical Environment: I am happy with my home and my community.
Self-Care: I regularly take "me time" to support myself.
Play: I know how to "play" and enjoy myself.
My readiness to make changes or improvements to my sense of connection:
On a scale of 1-10 (1 = lowest; 10 = highest), the importance to me of having a high level of connection is:
On a scale of 1-10 (1 = lowest; 10 = highest), my confidence level in my ability to reach and sustain a high level of connection is:
MEANING
Career: The work I do harnesses my strengths and experience. It suits me well.
Personal Growth: I am always learning new things and developing as a person.
My readiness to make changes or improvements in my life meaning.
On a scale of 1-10 (1 = lowest; 10 = highest), the importance to me of having a high level of meaning is:
On a scale of 1-10 (1 = lowest; 10 = highest), my confidence level in my ability to reach and sustain a high level of meaning is:
MEDICAL HISTORY
General Health
Complete the following statement: In general, my overall health is...
Pain: My bodymind feels good most of the time and I rarely hurt.
Physician Relationship
Do you have a primary care doctor whom you trust and see regularly?
Physical Exam
When was your last physical examination? Within the last...
Women's Health
Mark all that apply.
Medications
How often do you use drugs or medicines (including prescription and nonprescription) that treat depression, affect your mood, help you relax, or help you sleep?
Health Limitations
During the past 4 weeks, how much difficulty did you have doing regular activities as a result of your personal health?
FINAL THOUGHTS