Intake Form - Raeburn Coaching

Intake Form

Name(Required)

First Last

Birthdate(Required)

Phone(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Preferred Method of Communication(Required)

How did you find me as your coach?

(e.g., friend, referral, Google search, provider directory, etc.)

Why are you seeking coaching at this time?

In your own words, describe your current concerns/stressors as you see them:

How long has this been going on?

What prompted you to seek coaching?

What are your goals for our work together?

Have you worked with a coach before? If yes, please briefly describe the experience and any takeaways.

Have you participated in any personal or professional development programs or courses in the past? If so, which ones?

What is your marital status? If you are in a relationship, please describe the nature of the relationship and months or years together.

Do you have children? If so, what are please provide name and age:

Describe your current living situation. Do you live alone, with others. With family, etc…

What is your level of education? Highest grade/degree and type of degree.

What is your current occupation? What do you do? How long have you been doing it?

Who is your employer?

Are there any business or occupational challenges you're currently facing?

Please list anything else that is important for us to know about you that would assist us in working with you to achieve your desired results:

On a scale of 1-10, how would you rate your current occupational satisfaction? (10 being MOST satisfied)

Please enter a number from 1 to 10.

On a scale of 1-10, how would you rate your current life satisfaction? (10 being MOST satisfied)

Please enter a number from 1 to 10.

Is it ok to text you?(Required)

Yes

Is it ok to email you?(Required)

Yes

From time to time, I may send out greeting cards, etc. Would you be comfortable receiving mail at your home or office address? *(Required)

Yes

If you prefer we mail to an address other than the one listed above, please list the address here:

Disclaimer: Coaching is not therapy. Raeburn Coaching does not provide therapy, diagnosis, or any form of mental health treatment. If you live in Florida and would like to learn more about our clinical psychology practice, visit carolinaraeburn.com