Purpose: This form is designed to gather essential background information about clients, including their goals, challenges, personal history, and any relevant health or well-being details. The information collected will help the Coach tailor the coaching program to meet the client’s specific needs.

1. PERSONAL INFORMATION

Please provide your basic contact details. This information helps us stay in touch and schedule sessions.

Full Name:
(Input Field)

Preferred Name (if different):
(Input Field)

Email Address:
(Input Field)

Phone Number:
(Input Field)

Time Zone:
(Dropdown list with time zone options)

Best Way to Contact You:
(Checkbox options)

  • Email

  • Phone

  • Text

  • Other: (Input Field)

Emergency Contact Name (optional):
(Input Field)

Emergency Contact Phone Number (optional):
(Input Field)

2. COACHING GOALS

Understanding your goals allows us to tailor the coaching experience specifically for your needs. Please describe what you would like to achieve through coaching.

Primary Goal(s) for Coaching:
(Input Field or Text Area)
(e.g., career growth, life balance, improved confidence, skill development, etc.)

Secondary Goals (if applicable):
(Input Field or Text Area)

Why are these goals important to you at this moment in your life?
(Text Area)

How will you measure success in coaching?
(Text Area)
(e.g., achieving specific milestones, feeling more confident, etc.)

3. CURRENT CHALLENGES

Understanding your current challenges helps us focus on areas where you need the most support.

What challenges are you currently facing that you want to address through coaching?
(Text Area)
(e.g., stress, lack of motivation, decision-making difficulties, time management, career direction)

How long have these challenges been affecting you?
(Input Field for text)

What have you tried so far to overcome these challenges?
(Text Area)
(e.g., strategies, therapy, self-help techniques, etc.)

4. PERSONAL HISTORY AND BACKGROUND

This section helps the Coach understand your personal context and any factors that might be relevant to your coaching journey.

Brief Background Information:
(Text Area)
(Please provide any relevant details that may help the Coach understand your situation—could include career history, life events, key turning points, etc.)

Past Coaching Experience (if applicable):

  • Have you worked with a coach before?
    (Radio buttons)

    • Yes

    • No

  • If yes, what was the experience like, and what did you find valuable?
    (Text Area)

What do you believe is holding you back from reaching your full potential?
(Text Area)

5. RELEVANT PERSONAL DETAILS

(This section may vary depending on the type of coaching you offer—e.g., health coaching, career coaching, life coaching, etc.)

Health Information (For health or wellness coaching, include relevant health or medical info):

  • Are you currently experiencing any physical or mental health issues that the Coach should be aware of?
    (Checkbox)

    • Yes

    • No

  • If yes, please explain:
    (Text Area)

Current Support Systems (e.g., therapy, mentorship, family, etc.):
(Text Area)

Is there any other personal or lifestyle information you think might be helpful for your Coach to know?
(Text Area)

6. PREFERENCES FOR COACHING

Please help us understand how you prefer to work with your Coach.

Preferred Coaching Format:
(Checkbox options)

  • One-on-One Sessions

  • Group Coaching

  • Combination of Both

  • Other: (Input Field)

Preferred Session Length:
(Radio buttons)

  • 30 Minutes

  • 60 Minutes

  • 90 Minutes

  • Other: (Input Field)

How often would you like to have coaching sessions?
(Radio buttons)

  • Weekly

  • Bi-Weekly

  • Monthly

  • Other: (Input Field)

What times and days work best for you?
(Text Area)
(e.g., weekdays after 5 PM, weekends, specific days)

7. CONSENT TO COLLECT AND USE PERSONAL INFORMATION

By completing this form, you are consenting to the collection and use of your personal information for the purpose of providing coaching services. This information will be kept confidential and will not be shared without your consent, except as required by law.

Do you consent to the collection of your data for coaching purposes?
(Checkbox)

  • Yes

  • No

Do you consent to receive occasional email updates about coaching materials, promotions, or services?
(Checkbox)

  • Yes

  • No

8. E-SIGNATURE & ACKNOWLEDGEMENT

By signing below, you acknowledge that the information provided is accurate to the best of your knowledge and that you agree to the terms of this coaching agreement.

Client Signature:
(Electronic Signature Field)

Date:
(Date Picker)