Prism Vibes Client Intake Form

Name *

Date *

Address *

Address Line 1

City

State

Email *

Please enter your email, so we can follow up with you.

Phone *

Date of birth *

Sex *

What are your pronouns?

Marital status *

Occupation *

Education *

How did you hear about us? *

All information will be kept confidential. Please answer the following questions: (Mark your level of agreement with each of the below statements)

I am optimistic. *

Not at all(1 2)
Somewhat (3 4 5 )
Very Much (6 7 8 )
Absolutely (9 10 )

I am satisfied with my life. *

Not at all(1 2)
Somewhat (3 4 5 )
Very Much (6 7 8 )
Absolutely (9 10 )

I am satisfied with my health. *

Not at all(1 2)
Somewhat (3 4 5 )
Very Much (6 7 8 )
Absolutely (9 10 )

I am satisfied with my financial situation. *

Not at all(1 2)
Somewhat (3 4 5 )
Very Much (6 7 8 )
Absolutely (9 10 )

I am satisfied with my social life. *

Not at all(1 2)
Somewhat (3 4 5 )
Very Much (6 7 8 )
Absolutely (9 10 )

I feel good about my personal relationships. *

Not at all(1 2)
Somewhat (3 4 5 )
Very Much (6 7 8 )
Absolutely (9 10 )

I’d like coaching on a particular issue. *

Not at all(1 2)
Somewhat (3 4 5 )
Very Much (6 7 8 )
Absolutely (9 10 )

I’d like coaching on general direction. *

Not at all(1 2)
Somewhat (3 4 5 )
Very Much (6 7 8 )
Absolutely (9 10 )

I’d like coaching on various issues. *

Not at all(1 2)
Somewhat (3 4 5 )
Very Much (6 7 8 )
Absolutely (9 10 )

I’d like work related coaching. *

Not at all(1 2)
Somewhat (3 4 5 )
Very Much (6 7 8 )
Absolutely (9 10 )

I’m not clear what I need coaching on *

Not at all(1 2)
Somewhat (3 4 5 )
Very Much (6 7 8 )
Absolutely (9 10 )

What are you expecting from this professional coaching experience? *

What methods have you used to help with your current situation? *

What are your three top priorities to tackle in this sessions? *

How often would you like to meet, and how long do you anticipate meeting with a coach to reach your objectives? *

Captcha *

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