Life Coaching Consultation Form If you are a human and are seeing this field, please leave it blank. Personal Information First Name * Last Name * Email * How often do you check e-mail? Home Phone Mobile Phone Age Month JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Day 123456789101112141516171819202122232425262728293031 Year 200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940 Place of Birth Social Information Relationship Status SingleDivorcedMarriedWidowed Where do you currently live? Do you have childrent? If yes, how many and how old are they? Do you have pets? If yes, describe your pets. Occupation How many hours per week do you work? Health Information Please list your main health concerns: Other concerns and/or goals: How is your sleep? Do you wake up at night? If yes, why? Do you take any supplements or medications? Please list: Any healers, helpers or therapies with which you are involved? Please list: Do you crave sugar, coffee, cigarettes, or have any major addictions? Preliminary Life Coaching Questions What specifically to you want out of coaching and what changes need to be made for you to consider this program successful? What do you see, hear or feel? What has happened in your life that led you to seek coaching? What are three things that I could do for you, to improve your life quickly and effectively? 1. 2. 3. Have you ever had coaching before of any kind? One-on-one lessons/training, therapy, or other relationships that could be considered similar to coaching? How do you think our coach-client relationship could become better than any previous experiences you have had with other coaches? What would you like me to do if you get behind on your tasks, achieving your goals or even dreams? Here are examples of how I can work with people. Please indicate which appeal to you. Do you have health concerns that you want help with (Weight loss, overall wellness, food addictions or bingeing disorders, specific health issues)? Select the check box(es) for areas of interest: Gain self-awareness and self-improvementRemove limitations, limiting beliefs, obstaclesAnxiety, anger, and/or stress managementAchieve an important goal in the futureOvercome fears, phobias, significant emotional eventsBecome more resourceful and able to access positive emotional statesGain clarity about vision, mission, purposeBrainstorm about strategies and ideasDesign goals and holding you accountable to actions to achieve themSupport through a transition or change in lifeHealth CoachingAdditional Comments Anything else you would like to share?