Client Intake Form

The Next Steps Coaching is happy to welcome you as a new client. We are excited to help you achieve your goals. Please complete the following complete this form prior to our first session.

First name

Last name

Phone

Birthday

Month

Day

Year

Spouse/ Partners Name (if applicable)

Children's name and ages (if applicable)

Number of co-parents

Important Issues

Please briefly outline any issues you would like to deal with and what you hope to achieve in the coaching setting:

Issue #1

Issue #2

Issue #3

Personal Profile

I would describe myself as:

Others would describe me as:

Three things I like about my life/ situation are:

If I could change three things about my life situation, they would be:

My greatest three accomplishments (so far) are:

Disclaimer: The Client is aware that the coaching relationship does not represent psychological

counseling or any kind of therapy. The Client is also aware that coaching results can vary and are

not guaranteed. The Client agrees that they are entering into coaching with the understanding

that the Client is responsible for their own decisions and results. The Client also agrees to hold

the Coach free from all liability for any actions or results for adverse situations created as a

direct or indirect result of advice given by the Coach. (Client initials) _________________

Session Contact Procedure: The Client shall contact the Coach at the agreed hour. If the Client

fails to make the appointment time, the Client is still responsible for the coaching fee, unless 24

hours notice was given to reschedule the call. The Coach will make every effort to reschedule

with the Client.

Do you agree to these terms?

Yes

Signature

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