Coaching Intake

Client Information

Legal First Name

Last Name

Coaching & Health History

Current Health Conditions

Previous Coaching Experience?

Self-Care & Lifestyle

Current Exercise/Movement Routine

Dietary Habits

Sleep Patterns

Desire to change your lifestyle? Selected: 5 / 10

1 (No desire) 10 (Extreme desire)

Challenge in maintaining a healthy lifestyle Selected: 5 / 10

1 (Not challenging) 10 (Extremely challenging)

Confidence in ability to maintain a healthy lifestyle Selected: 5 / 10

1 (Not confident) 10 (Extremely confident)

Stress & Emotions

How well do your stress techniques work? Selected: 5 / 10

1 (Don't work) 10 (Exceptionally well)

How motivated are you to manage your stress? Selected: 5 / 10

1 (Not motivated) 10 (Extremely motivated)

How confident are you that you can manage your stress? Selected: 5 / 10

1 (Not confident) 10 (Extremely confident)

What emotional regulation practices do you use?

Journaling Expressive writing Art, music, or creative expression Mindfulness or meditation Gratitude practice Emotional awareness / naming feelings Self-compassion or positive self talk Crying, laughing, or releasing safely Guided imagery or visualization

How well do your emotion techniques work? Selected: 5 / 10

1 (Don't work) 10 (Exceptionally well)

How motivated are you to regulate your emotions? Selected: 5 / 10

1 (Not motivated) 10 (Extremely motivated)

How confident are you that you can regulate your emotions? Selected: 5 / 10

1 (Not confident) 10 (Extremely confident)

Career Domain

This is an opportunity to reflect. There are no right or wrong answers.

Work satisfaction Selected: 5 / 10

1 (Not satisfied) 10 (Extremely satisfied)

Enjoyment at work? Selected: 5 / 10

1 (Not enjoyable) 10 (Extremely enjoyable)

Confidence at work? Selected: 5 / 10

1 (No confidence) 10 (Extremely confident)

Desire to make changes at work? Selected: 5 / 10

1 (Not desirable) 10 (Extremely desirable)

Motivation to make changes to your work? Selected: 5 / 10

1 (Not motivated) 10 (Extremely motivated)

How confident are you to make changes to your work life if you want to? Selected: 5 / 10

1 (Not confident) 10 (Extremely confident)

Challenges in your work/career

Relationships & Support

This section is for reflection about your current relationships (friends, partners, etc.) and support networks.

What are your primary relationships and support system goals?

Relationships and Support Systems (Satisfaction) Selected: 5 / 10

1 (Not satisfied) 10 (Extremely satisfied)

How necessary is it to make changes to your relationships and/or support systems? Selected: 5 / 10

1 (Not necessary) 10 (Extremely necessary)

How motivated are you to make changes to your relationships and/or support systems? Selected: 5 / 10

1 (Not motivated) 10 (Extremely motivated)

How confident are you to make your desired changes to your relationships and/or support systems? Selected: 5 / 10

1 (Not confident) 10 (Extremely confident)

How many barriers are there for you to make your desired changes to your relationships and/or support systems? Selected: 5 / 10

1 (No barriers) 10 (Many barriers)

Goals and Motivation

What are your primary coaching goals?

What motivates you to achieve these goals?

What challenges do you face in achieving your coaching goals?

Motivation to achieve coaching goals Selected: 5 / 10

1 (Not motivated) 10 (Nothing can stop me)

Confidence in achieving coaching goals Selected: 5 / 10

1 (Not confident) 10 (Extremely confident)

Barriers in achieving coaching goals Selected: 5 / 10

1 (No barriers) 10 (Significant barriers)

Confidence in overcoming barriers Selected: 5 / 10

1 (Not confident) 10 (Extremely confident)

Support in achieving your coaching goals? Selected: 5 / 10

1 (Not supported) 10 (Very supported)

What support systems do you currently have in place?

Talking with friends Coaching or therapy Support groups Mentorship or spiritual Volunteering / Acts of service

Are there any other factors you believe are important for your coaching journey?

Review & Finalize

You have mapped your baseline. Please sign below to complete your intake.

I hereby confirm that the information provided in this assessment is accurate to the best of my knowledge. I understand this establishes the baseline for our confidential coaching container.

Electronic Signature

Date

Intake Successfully Completed

Final Steps:

Download your completed assessment as a PDF below.
Email the PDF directly to [email protected]
Proceed to the final Client Portal setup.

Step 3: Proceed to Next Step

Secure Client Portal

Client Information

Coaching & Health History

Self-Care & Lifestyle

Stress & Emotions

Career Domain

Relationships & Support

Goals and Motivation

Review & Finalize

Intake Successfully Completed

Final Steps: