DR. MAREK COACHING
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CLIENT DATA FORM 
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Date:  _______________________
 
Name: ___________________________________________________________________________
 
Occupation: _______________________________________________________________________
 
Business Name:  ___________________________________________________________________
 
Home Address:  ___________________________________________□ Preferred Address
 
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Business Address: ___________________________________________□ Preferred Address
 
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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.):
 
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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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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? _____________________________­­­­­­­­­­­­­____________________________________
 
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What stops you from having the life you want to have? ________________________________________
 
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Website created & managed by
Prajwal Rajthala

prajolrajthala@gmail.com
CONTACT DR. MAREK
 Registered as LLC
at​ the Colorado  Secretary of State Office,
ID number:
20208067983
  • HOME
  • ABOUT
    • MISSION
    • THE COACH
    • TESTIMONIES
    • GALLERY
  • INDIVIDUAL COACHING
  • ONLINE WORKSHOPS
  • EMPOWERING ACTIVITIES
  • APPOINTMENTS