This preliminary client intake form is required to see if we are a good fit for each other. Please answer truthfully so I can best assess the help I can give to you.

All information is confidential and will not be shared with any third parties

Client Intake Form

Email

First name

Last name

Address

Phone

Date of Birth

Occupation

Marital status

Children & ages

Client Goals

Here's where you tell me specifically what your challenges and goals are? It's important to be transparent in your answers so that know if you are the right fit for coaching with me.

Do you have any self image challenges? i.e. weight, skin conditions, mobility challenges, feeling old

What methods have you used to improve your self image?

Plastic Surgery

Image Consultant

Weight-loss Program

Other

What is your main motivation for achieving an improved self image?

Would you say that you have mental blocks from feeling self confident in your self image or physical blocks, or a combination of both?

When you think of your life, what has been your biggest success? What did you do to accomplish it?

Do you know anything about building feminine sexual energy?

Have you ever worked with a coach before and what were the results you needed them to help you achieve?

Do you consider yourself a feminine woman?

Are you currently seeing a therapist or psychologist, for how long and why?

Do you have a regular religious practice: go to church, mosque, synagogue

What do you currently value the most in your life: Family, Money, Marriage, Life Purpose

Do you respond to directness (tough love) or do you prefer a gentle style of support and giving directives?

Tough Love

Gentle Support

Combination of Both

When faced with criticism, how do you handle it?

How often do you need to review your progress? How would you like to review it?

How can I best support you as your coach? What do you most need from me?

Lifestyle

Based on your personality and needs, How frequently would you like to work with a personal coach?

1 session per week

biweekly sessions

1 mega session 3-4 hour per month

Other

What is a comfortable coaching budget (12 month cycle) that you can commit to for private one on one coaching?

20k-30k

15k-20k

12k

Testimonial

Client Intake Form

Client Goals

Lifestyle

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