Coaching Intake and Release Form

Your Name *

Call preference *

Your Phone Number (if Telephone)

Your Skype ID (if Skype)

Your Email *

Your URL

Your birthdate *


Spouse Birthdate

Children Names and Ages

Occupation *

Company *

Do you have any health problems?*

If yes, please describe.

Are you currently on any medications?*

If yes, which?

Have you ever seen a counselor or therapist?*

If yes, when and why?

How do you learn?*

Favorite Hobbies/Sports/Interests:*

Who do you most admire and why?*

What are you most pleased and proud of having accomplished? Why?*

What are your personal and professional strengths?*

What is your passion in life? What makes you happiest? What fulfills you? What excites you?*

What do you offer that is unique to you?*

What are your personal life goals for the next 90 days?*

What are your professional goals for the next 90 days?*

What motivates you? Why do you do what you do? (professional or personal)*

List 10 things that make you smile.*

What else do you want me to know about you?*

What goals do you have for this coaching relationship?*

Confidentiality: All interactions with you are kept strictly confidential.

Results: You are responsible for producing results and your decisions are your own. My responsibility is to explore with you the opportunities and possibilities available. I will be your #1 advocate, cheerleader and coach and will assist you in building the life you want. I will respect your life choices.

Initial Focus of Our Work:

Call Policy:
I will call you at the designated time of our appointment at the number or Skype user that you have chosen.

If I have to change an appointment, I will always reschedule it as soon as possible

If you need to cancel or reschedule the session, please give 24-hour notice. We will reschedule to a mutually acceptable time. Emergencies will be dealt with as they arise.

Forgetting or just missing an appointed call are not emergencies. Missed appointments or non-emergency cancellations with less than 24-hour notice may be difficult to reschedule and will count as one of your scheduled calls.

Consent: I have read the above information and policies and have clarified any questions I have. I agree to the stated terms.

Type Your Name: