New Client

Preferred Name *

First

Last

Best Contact Number *

Select One *

Alternate Contact Number *

Select One *

If divorced, separated or widowed, how recently: *

Number of children if any: *

Age range of children if any: *

Number and type of pets if any *

In Case of Emergency Name *

Phone Number *

Has your general health increased or decreased over the last year? *

Increased Decreased About the same

How do you feel about your general health *

Satisfied No opinion Not Satisfied

Has your fitness level increased or decreased over the last year? *

Increased Decreased About the same

How do you feel about your fitness level? *

Satisfied No opinion Not Satisfied

Do you smoke *

No Daily Occasionally

How stressful is an average day? *

Very Stressfull Somewhat stressful Not stressful

How good do you feel about how you handle stress? *

I think I handle it well I have my good and bad moments It is a frequent problem

How do you feel about your amount of "down time" in an average day? *

There is never enough I make good use of the time I have I have too much time on my hands

List any hobbies or activities you do to relieve stress *

How happy do you feel in general? *

Almost always happy Usually happy Sometimes happy Rarely happy

How do you think others would rate your average level of happiness? *

Almost always happy Usually happy Sometimes happy Rarely happy

How would you rate your self esteem over the last 6 months *

Very good Average Low Very low

How do you normally feel when you wake up and consider the day ahead? *

I look forward to the day I look forward to the end of the day I try to avoid thinking about it at all I have to fight to get out of bed

Are there any physical, mental or emotional issues that I should know about? *

Yes No

Please explain if yes to the previous question. *

Have you ever seriously considered suicide? *

Yes No

If yes to previous question, have you ever acted on it? *

Yes No

If yes to previous question, how many times? *

What, specifically, do you want to accomplish with this coaching, i.e weight loss, increased financial abundance, increased job satisfaction, overall life satisfaction, increased spirituality, quitting smoking? If more than one, please consider carefully and prioritize according to a "I have to" priority to a "It would be nice to". *

Please elaborate on any "I have to" priorities, i.e. "My doctor says I'll die if I don't", "I will lose my house, children, job, etc.". *

How do you think your life will be different once you accomplish this goal? *

What, if anything, have you done in the past to achieve this goal? *

What would you say prevented previous success in achieving this? *

What external influences finally brought you to the decision to consult a life coach? *

Is there another person or group that would support you in achieving this goal? *

Yes No Maybe

What do you feel is the current state of reaching your goal? *

I just started thinking about it in the last month or less, but haven’t been ready to take action. I’ve been thinking about it for a couple of months or more, but haven’t been ready to take action. I'm ready to take action but have no idea where to start. I'm ready to take action and have some thoughts about where to begin. I have been actively working towards this goal for less than three months. I have been actively working towards this goal for 3 months or more. I feel like I’ve been working on this goal for years but have not made any lasting progress.

Describe a typical day. *

What would you say is your favorite part of the day. *

What is your least favorite part of the day. *

Do you truly enjoy what you do throughout most of every day? Why or why not? *

If money weren't an option, what, if any, field of employment would you be in? Why? *

Do you currently feel like, every day, you are getting closer to your primary goal, getting further away from it or stagnating in your progress? Please explain. *

How do you feel about progress on your other goals? *

Are you TRULY ready to make changes that will positively affect your life in a positive way? Change can be extremely difficult, especially when we have been building habits and perceptions for long periods, sometimes for our entire lives. CRC Life Coach is not interested in taking peoples money or wasting your or our time for services that will not make long term lasting benefits for you. We realize our services are not inexpensive and are convinced that you must be truly ready to dedicate the time and money to make permnent and lasting changes in your life. If you are ready to commit to changing, knowing that sometimes we must destroy old habits, patterns and beliefs in order to build a better life for ourselves, then PLEASE continue by acknowledging below. *

I am ready to change my life! No, forget I contacted you please

Acknowledgements of Liability or Lack Thereof

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I understand that all CRC Life Coaches are independent agents, that CRC Life Coach makes no guarantees on services rendered by these agents and takes no liability whatsoever for any advice given by them. All advice is given with the best of intention, cannot be misconstrued as anything other than that and is the clients full responsibility to either choose to follow such advice given. Unless otherwise stated, CRC life coaches are not licensed medical or counseling professionals and will not provide medical advice of any kind, although it may be suggested or the client may be referred to such professionals. Please be aware that if, after evaluation, CRC Life Coach determines that more professional advice is required than we can provide, we will state this and suggest this path before accepting you as a new client. *

I Acknowledge I do not agree and wish to cancel

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