Client Intake form

Here’s a Client Intake Form template that can be used for gathering essential information from clients. This form is designed to help you understand their background, goals, and needs in the context of an integrative wellness or life coaching practice.

First Name *

Last Name

Date of Birth *

Phone *

Email Address *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Personal Information

Occupation *

Marital Status *SingleMarriedDivorcedWidowedOther

Do you have children? *YesNo

If Yes, How many?

Emergency Contact *

Emergency Contact Phone *

Health and Wellness Background

What brings you to Peace For Your Pieces? (Check all that apply) *Stress ManagementAnxiety/DepressionLife TransitionHealth ConcernsCareer/Business CoachingRelationship IssuesSpiritual Development

Other (please specify):

Current Health Status:

Current Health Status:

Physical Health: How would you describe your overall physical health? *ExcellentGoodFairPoor

Emotional/Mental Health: How would you describe your mental and emotional well-being? *ExcellentGoodFairPoor

Do you have any current or past medical conditions? *YesNo

Are you currently taking any medications or supplements? *YesNo

If Yes, Please list

Checkbox *AlcoholTobaccoRecreational DrugsNone

Do you have any physical limitations or disabilities? *YesNo

Text

Life Assessment and Goals

What area of your life do you feel the most imbalance? (Check all that apply) *MentalEmotionalPhysicalSpiritualCareer/ProfessionalRelationships

What specific goals would you like to work on with your life coach?

Have you worked with a life coach, therapist, or other wellness practitioner before? *YesNo

If yes, please briefly describe your experience:

Spiritual and Personal Development

Do you practice any spiritual or religious beliefs?YesNo

If yes, please describe:

Financial and Career Considerations

Current Occupation/Job Title:

Are you satisfied with your current career or job?YesNo

If no, what would you like to change?

Additional Information

Preferred Meeting Locations: (Check all that apply) *In-personVirtualPhone

How did you hear about Peace For Your Pieces? *

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