Kristi Reeves

Coaching To Connect

Intake Form

Coaching With Kristi

649 South 700 East, Orem Utah 801-400-2460

Please read the terms and conditions of this online form below, then fill out the actual form further below.

Intake Form

Your Name:

Your Address:

Cell Phone:

Your Email:

How did you hear about Kristi?

Gender

Male

Female

Age:

Date of Birth:

Place of Birth:

Relationship Status

Married

Un-Married

Divorced

Separated

Number of Children:

Ages of Children:

Education:

High School

Some College

BA/BS

MA/MS

PHD

Other

Field of Study:

Additional Background:

What one major goal would you like to accomplish within the next 12 Months?

What has been your greatest challenge?

What would you like to work on while working with me as your life coach?

Have you worked with a coach before, or a similar one on one relationship (e.g: a piano teacher, tennis coach, therapist)? If so, what worked well, and what did not work well?

List five things that you’re personally tolerating or putting up with in your life at present. (Examples: information you can’t find, clutter, rude friends, tight shoes, dented car, job dissatisfaction, dead plants, broken equipment, cranky people in your Life, disconnected relationships. etc.)

In a typical week, what do you spend a great amount of time doing?

What are your primary stressors? (What stresses you out?)

On a scale of 1-10 (10 being high) rate the quality of your life:

On a scale of 1-10 (10 being high) rate the quality of your health:

On a scale of 1-10 (10 being high) rate the amount of stress you have:

I (First & Last Name)

Agree to the terms and conditions listed above. By clicking this checkbox and submitting this form, I acknowledge this to be an electronic signature that is as binding as a physical signature.

Electronic Signature

I have read all of the Policies & Procedures

Yes

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Coaching Intake Form.1.pdf