CHAMPION COACHING

Name

First NameLast Name

Age

Date of Birth

Date

Phone Number

Format: (000) 000-0000.

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Marital Status

Occupation

Are you currently taking any medications?

If yes, then please indicate the medication name and the purpose below:

Do you have any health condition that you would like to share?

If yes, then please share them below:

What are some of your personal goals?

Do you have any professional goals you would like to share with your coach?

What changes would you like to make in your life right now?

What are the things that upset you?

What are the things that makes you happy?

What is your motivation in life?

What are you willing to do to achieve your goals?

What are your professional strengths and assets?

What are your expectations from this coaching relationship?

AGREEMENT/REMINDERS:

I understand that all information I entered in this form will be considered strictly confidential.

The data gathered from this form will only be used as a basis for the type of coaching the client will need.

I understand that in order to be successful, it is vital to follow the plan agreed by both the life coach and the client.

I have read and signed coaching disclaimer and waiver.

COACHING FEE

60 minute Session - $50.00

Payment Options - Cash or Apple Pay

Payment due upon receiving services.

How did you find out about our services?

Other

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