Intake Form Private Coaching

Intention setting private coaching

First name

Last name

Emergency contact name + number

Describe any current health issues or pains.

Have you ever had (recently or in the past) a physical or psychological trauma? Describe briefly. Put the date/year it happened. These can be big or small traumas.

Briefly describe the relationship with your main caretakers and siblings when you grew up and now, and how you felt/feel about this.

What is you relationship with (recreational) substances like drugs and alcohol?

Do you have a spiritual belief system? Are you an Atheist? Religious? Describe briefly.

How do you describe your current lifestyle, when it comes to work-life balance, movement, sleep and food?

What do you want accept and release in the coming 6 months?

What do you want to achieve in the coming 6 months?

Based on the above, state you 3 most important intentions, in positive language. (e.g. instead of "not anxious" you could write "peaceful and confident.")

For each of the 3 intentions, list WHY you want this. Why is this so important or exciting to you?

For each of the 3 intentions, what would it look like if you turned it up x10?

For each of the 3 intentions (or their x10 version), write down how you can make this measurable to yourself. How will you know you have achieved them?

For each of the 3 intentions, describe in detail what you will see, hear, feel, ... the moment you "have arrived."

Once you have arrived, what will be possible for you then? What will be the next dreams or steps?

If you think about "your highest self" (the highest possible version of you), how would you describe them, what are they like?

As you are writing all of this down, which limits, fears and "but ..."-thoughts are coming up for you?

How do you usually self sabotage? Where or how could you give up, shut down or escape, during the process?

How can you counter these moments?

How can I hold you accountable when you go off-track?

What areas would you like me to support you with most, in the coming months?

What are you most nervous about, when it comes to this coaching trajectory? What could make you feel more at ease about this?

How will you know this coaching partnership was a success for you? What will be the proof?

Are you ready to go fully in and give it your all? Are you ready to go deep and stay present with yourself even when it feels uncomfortable? Are you ready to dedicate attention, time, and energy to yourself? If not, why? How can you solve this?

Do I have your permission to be very honest, so that I can hold you accountable to the best version of yourself when your own limits or self-sabotaging patterns get in your way?

100% YES

Not sure.

No.

Is there something else you want to share or tell me? Something else I should know about you? A message you want to share? A question? Shoot!