Personal/Integrated Coaching Discovery Form

This client intake form is intended for informational purposes to assist your coach in getting to know you as well as to begin to establish a solid basis for the coaching relationship. The information you provide will be kept in strict confidence unless you explicitly grant an exception. Please take your time in completing the form. If you choose not to answer any questions, just mark them N/A. This intake form is designed to capture your vital statistics, information about your background, and present situation. We value your input and responses to these questions and look forward to our coaching together.

Name *

Name

First Name

Last Name

Tel No *

Email Address *

Date of Birth *

Date of Birth

YYYY

Have you tried coaching before? How was your experience? *

What are your expectations from coaching? *

What is the topic/issue you would like to be coached on? What makes this a topic/issue for you? How long have you been attempting to address this? What have you tried so far? Have your attempts been successful? Why or why not? What do you think it will take to address this topic/issue successfully? What leads you to believe that coaching can help in this process? *

Self Assessment - Current

Rank (1-5, 1 = weak, 5 = Great) and describe your competence in these areas of your life (now).

1. Cognitive: The ability to make observations, discern, analyze and synthesize what you have observed with intellectual rigor. This is the realm of the intellect.

2. Somatic: The ability to be aware of bodily states in oneself and others, while appropriately responding to those states with attention and care. This is the realm of awareness and care of the body.

3. Emotional: The ability to observe and discern your own and others' affect, mood and emotional state and to stay present and settled with whatever arises moment to moment.

4. Relational: The ability to initiate and sustain rich, mutually satisfying relationships across and in all domains of your life.

What practices currently support you in having a meaningful life? What frequency, duration do you engage in these practices? What allows you to sustain? What takes you away?

Self assessment - Past

What have been the five or six defining moments in your life? *

Describe a time in your life that you felt vibrant, alive and fulfilled. What were the circumstances? How did you feel? What were you engaged in? What was the environment like? Who and what supported you? What is the feeling of support for you? *

Reflect on the few significant people in your life, who have greatly influenced you. What about them touched you? Any patterns that you see? *

Self assessment - Future

Imagine a time ahead, when you are ninety-six or seven. You are looking back on your life. How might your friends and family describe you? What qualities would they refer to? Accomplishments? What about you inspired you? What regrets do you have? What are you most proud of? Inspired by? What counsel would you have for yourself? *

Is there anything else that you would like to share that might be helpful?

Personal Coaching Discovery Form

Personal/Integrated Coaching Discovery Form