Client Intake Form-TheSaltyAlchemist

Client Intake Form

In order for me to get to know you and what you're wanting to achieve in our work together, please complete the following form.

First Name

Last Name

Date of Birth

Age

What's your relationship status?

Single

In a relationship

Married

Divorced

Widow

What's your profession and/or professional status at this time?

What days and times are you available for your coaching sessions? Be sure to let me know if you have a particular preference.

Monday

Tuesday

Wednesday

Thursday

Friday

Morning (8-11)

Afternoon (12-4)

Evening (5-7)

How did you hear about my work?

What prompted you to seek coaching at this time?

On a scale of 1-10 how content are you with your life currently? 1 being Not satisfied and 10 being Very satisfied

What is the thing that matters most to you right now in your life that you want to create, improve, or experience more of?

What would you like to achieve in your coaching sessions with me? Select one or more from the list below.

Manage Stress

Gain work/life balance

Improve my self-esteem

Learn to deal with feelings

Understand what motivates me

Identify goals and action steps

Become more productive

Improve my relationships

Get support and encouragement

Improve my communication skills

Move through trauma

Release self-limiting beliefs

Other

If you checked other, please feel free to use this space to elaborate.

Is there anything else you'd like to share with me before we start working together?

Please don't hesitate to reach out via email info@thesaltyalchemist.com if you have any questions.

I'll be in touch within the next 48 hours to schedule our sessions.