CLIENT DATA FORM
Date: _______________________
Name: ___________________________________________________________________________
Occupation: _______________________________________________________________________
Business Name: ___________________________________________________________________
Home Address: ___________________________________________□ Preferred Address
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Business Address: ___________________________________________□ Preferred Address
___________________________________________________________________________
Day Phone: __________________________ Evening Phone: _______________________________
Fax Line: ___________________________ Cell Phone: ___________________________________
E-mail Address: _____________________________________________________________________
Okay to leave messages everywhere? ____ If not, explain: ___________________________________
Preferred means of communication: ______________________________________________________
Date of Birth:__________________________________________ Age: __________________________
Other Significant Dates: ________________________________________________________________
Preferred Coaching Schedule: on (day of week) _________ [or} (time of day) ______________________
Names of important people in your life (spouse, partner, children, friends, etc.):
____________________________________________________________________________________
____________________________________________________________________________________
Emergency Contact: ___________________________________________________________________
Other information you want me to know: (You may continue on back of page.) ______________________
____________________________________________________________________________________
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How did you hear about my coaching services? ______________________________________________
What influenced your decision to work with a coach? __________________________________________
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Have you ever been coached? If so, please describe the experience? ___________________________
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Do you have specific goals for the coaching relationship? If not, what goals might you now create? ____
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What are your significant commitments? ___________________________________________________
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____________________________________________________________________________________
____________________________________________________________________________________
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What would your perfect life look like? ___________________________________________________
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What are your dreams? ________________________________________________________________
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What dreams have you given up on? ______________________________________________________
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Where do you want to focus first? ________________________________________________________
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What parts of your life are working best now? ________________________________
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____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
What parts of life are working least well? ____________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
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What are your values? _________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
What stops you from having the life you want to have? ________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Date: _______________________
Name: ___________________________________________________________________________
Occupation: _______________________________________________________________________
Business Name: ___________________________________________________________________
Home Address: ___________________________________________□ Preferred Address
___________________________________________________________________________
___________________________________________________________________________
Business Address: ___________________________________________□ Preferred Address
___________________________________________________________________________
Day Phone: __________________________ Evening Phone: _______________________________
Fax Line: ___________________________ Cell Phone: ___________________________________
E-mail Address: _____________________________________________________________________
Okay to leave messages everywhere? ____ If not, explain: ___________________________________
Preferred means of communication: ______________________________________________________
Date of Birth:__________________________________________ Age: __________________________
Other Significant Dates: ________________________________________________________________
Preferred Coaching Schedule: on (day of week) _________ [or} (time of day) ______________________
Names of important people in your life (spouse, partner, children, friends, etc.):
____________________________________________________________________________________
____________________________________________________________________________________
Emergency Contact: ___________________________________________________________________
Other information you want me to know: (You may continue on back of page.) ______________________
____________________________________________________________________________________
____________________________________________________________________________________
How did you hear about my coaching services? ______________________________________________
What influenced your decision to work with a coach? __________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Have you ever been coached? If so, please describe the experience? ___________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Do you have specific goals for the coaching relationship? If not, what goals might you now create? ____
____________________________________________________________________________________
____________________________________________________________________________________
What are your significant commitments? ___________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
What would your perfect life look like? ___________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
What are your dreams? ________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
What dreams have you given up on? ______________________________________________________
____________________________________________________________________________________
Where do you want to focus first? ________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
What parts of your life are working best now? ________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
What parts of life are working least well? ____________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
What are your values? _________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
What stops you from having the life you want to have? ________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________