BEHAVIORAL CHANGE - INITIAL INTAKE

First name

Last name

Birthday

Month

Day

Year

Email

Address

SECTION 1 - YOUR COACHING SESSION

What prompted you to seek coaching at this time?

What feels stuck or misaligned?

Describe your biggest current obstacle:

SECTION 2 - PATTERNS

What patterns do you notice repeating in your life?

When do you typically self-sabotage?

What triggers overwhelm?

If things shifted positively in 6 months, what would look different?

What are you avoiding?

On a scale of 1–10, how ready are you for change?

What might get in the way?

Are you willing to take uncomfortable action?

Yes

No

Unsure

Are you currently under psychological or psychiatric care?

Yes

No

Coaching does not replace therapy. Please check to confirm you understand.

SECTION 3 - COACHING AGREEMENT & CONSENT

I understand that coaching is not psychotherapy, counseling, or medical treatment. Coaching is a collaborative process focused on growth, clarity, and accountability. I take full responsibility of my actions and decisions.

I agree

Date

Month

Day

Year

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