Life Coaching Intake Form

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Client Information

Full Name:

Date of Birth:

Phone Number:

Email Address: *

Preferred Method of Contact:

Phone
Email
Text

Address:

Emergency Contact Name:

Emergency Contact Phone:

Background Information

1. What motivated you to seek life coaching at this time?

2. Have you ever worked with a life coach, therapist, or counselor before?

If yes, please share any relevant details:

3. What areas of your life are you looking to improve or focus on (e.g., career, relationships, health, personal development)?

4. Do you have any specific goals or outcomes you hope to achieve through life coaching?

5. What are your current strengths that you believe will support your growth?

6. What challenges or obstacles do you feel are currently holding you back?

life Preferred with

Health & Wellness

1. Do you have any health conditions or concerns we should be aware of?

(Please list or write “None”)

2. How do you currently manage stress and take care of your well-being?

Lifestyle & Habits

1. Describe a typical day in your life, including your routines and habits.

2. How do you balance work, family, and personal time?

3. Do you have any hobbies or activities that bring you joy and fulfillment?

Expectations & Preferences

1. How often would you like to have life coaching sessions?

Weekly
Bi-weekly
Monthly

Other:

2. Do you have any preferences for session format?

In-person
Virtual
Phone

3. Is there anything specific you would like your life coach to know about you or your expectations for the coaching experience?

Waiver of Liability & Consent

I, the undersigned, understand that life coaching is a professional relationship designed to support personal and professional growth. I acknowledge that life coaching is not a substitute for medical, psychological, or other professional advice, diagnosis, or treatment.
I agree to assume full responsibility for any outcomes or decisions made as a result of participating in life coaching sessions. I release Leaves of Change, LLC, its coaches, and any affiliated entities from any and all liability for any injuries, claims, or damages that may result from my participation in life coaching services.
I understand that all information I provide is confidential and will be used solely to support my life coaching experience.

Client Signature:

Date:

Photo & Media Release (Optional)

I give permission for photos or videos taken during sessions or events to be used for promotional purposes by Leaves of Change, LLC. I understand that I will not receive compensation for the use of these images.

leaves of change: a healing arts practice

nurturing growth healing and transformation