Life Coaching Intake Form - MuscleMind

Coaching Intake Form

Please complete this form before scheduling your first appointment. You may save this form and complete it later by clicking the button at the bottom of the form. Once the form is complete, you will be redirected to our scheduling portal.

"*" indicates required fields

Name*

First Last

Date of Birth*

Age*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Cell Phone*

Home Phone

(If Different from Cell)

Email*

Occupation*

Primary Physician

Physician Phone #

Emergency Contact

Relationship to You

Emergency Contact Phone #

How did you hear about me?

Marital Status

Single

Married

Partnered

Divorced

Widowed

If you are partnered, how long in your current relationship?

Please list the people that are currently living with you below, including their name, their relationship to you, and their age.

Why are you coming in for coaching at this time (goals, problems, issues, etc.)?

What do you hope to achieve upon completion of coaching?

Please rate your life in the following areas, where 0 is low/bad and 10 is high/good.

Please add whatever degree of clarification you like. Of course, all responses are held in the strictest professional confidentiality.

What is your experience of your own:

1. Well-being—physical body

Please enter a number from 0 to 10.

2. Well-being—emotional

Please enter a number from 0 to 10.

3. Well-being—mental

Please enter a number from 0 to 10.

4. Well-being—spiritual

Please enter a number from 0 to 10.

5. Financial freedom/security

Please enter a number from 0 to 10.

6. Family relationships

Please enter a number from 0 to 10.

7. Friendships

Please enter a number from 0 to 10.

8. Romantic relationship

Please enter a number from 0 to 10.

9. Career achievements

Please enter a number from 0 to 10.

10. Environment—home

Please enter a number from 0 to 10.

11. Environment—work

Please enter a number from 0 to 10.

12. Overall satisfaction

Please enter a number from 0 to 10.

13. Service to others

Please enter a number from 0 to 10.

14. Joy

Please enter a number from 0 to 10.

15. Guilt

Please enter a number from 0 to 10.

16. Success

Please enter a number from 0 to 10.

17. Generating your life vs. Reacting to the circumstances of life

Please enter a number from 0 to 10.

If you want to explain any of the items above, please list the item number with explanations below:

1. What is working about your life?

2. What would your life look like if it were your dream life?

3. What is stopping you from doing or achieving what you are committed to in life? (Please also list any past trauma issues, mental health/physical health issues, unsafe environment, etc.)

4. What is (are) your biggest challenge(s) in life?

5. What are the five critical success factors of your life (if these areas were handled, your life would be a success)?

Please list below the objectives, end results, and measurements of success that you would like to have by the time we finish working together (you may list up to five, or copy this page to list more).

Objective 1:

Measurement of Success:

Objective 2:

Measurement of Success:

Objective 3:

Measurement of Success:

Objective 4:

Measurement of Success:

Objective 5:

Measurement of Success:

Please tell me your life story, and be as detailed and creative as you want. Please also list any important dates at the end (such as anniversary dates, birthdates, etc.).

If we are coaching by phone, please send me a picture of yourself. This will allow me to feel more connected to you in order to better partner with you.

Max. file size: 512 MB.

Phone

This field is for validation purposes and should be left unchanged.

“Look, feel, and be your best! Talk with Doc today!”

MuscleMind, LLC

doc@musclemind.net
802.468.7253

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