Client Intake Form - Live Inspired Coaching

Name *

First

Last

Date of Birth *

Email *

Home Phone

Cell Phone *

Street Address *

City, State, Zip *

Describe your reason or recent events that have encouraged you to seek life coaching. *

What are you wanting most in life right now? *

Who are you when you're at your best? *

What do you hope to accomplish with life coaching? *

What other complementary therapies have you tried in the past? When? What did you find to be beneficial? *

What is your profession? *

How many hours per week do you work? *

What is the level of stress in your job (scale of 1 to 10; 1 being the lowest, 10 being the highest)? *

How long have you worked in your current job or owned your business? *

What is your level of stress in your life in general right now (scale of 1 to 10; 1 being the lowest, 10 being the highest)? *

What methods do you employ to help manage the stress in your life right now? *

What methods have you employed to help manage stress in the past? *

Please list any physical or mental health issues in the past 10 years. *

Please list any physical or mental health issues 10 years or longer. *

Please list your health care providers (primary care, mental health, and alternative providers) and if you are regularly seeing a health care provider for any particular concerns. *

List current medications/herbs you are taking and for what reasons: *

Briefly describe your diet or eating habits: *

How many glasses of water do you drink per day? *

How many caffeinated beverages do you drink per day? *

How many alcoholic beverages do you drink per day/week? *

Please describe your sleeping patterns: *

If you have children, please list their names and ages.

Emergency contact name, phone, and relationship to you. *

Please describe any other concerns you would like to bring to my attention.