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Intake Form | Christopher Coleman

First Name:
Last Name:

Phone Number:

Date: / /


Please rate your current level of satisfaction with each of the following areas of your life. Place a number from 1 to 10 in the box to each item, 1 meaning “entirely unacceptable to me in its current state” and 10 meaning “I couldn’t be happier with this.” Skip any that do not apply. Your level of satisfaction with each may change somewhat from day to day, but try to give your best overall assessment of how pleased/peaceful/fulfilled/content you are with each at this point in your life.

Personal Spiritual Life and Growth
Relationships with Clients
Quality of day-to-day life
Physical Health
Mental/Emotional Health
Family Relationships with Extended Family
Romantic Relationship

Relationships with Children:

Friends/Social Life
Fun and Recreation/Hobbies
Financial Stability

Physical Environment:

Condition of Home, Office, Cars, Neighborhood, etc.

Describe in more detail 1-5 areas you’d most like to focus on.


If you could have the results you desired in these 1-5 areas, what specifically would like to achieve in the next 90 days?

What would you have to do or change to make these things happen in the next 90 to 180 days?

As a coach, how can I best support you to achieve your goals?

I would like my sessions to be held by (required):