Client Intake Form | Reboot Mindset Coaching

Name *

First

Last

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Date of birth *

Emergency Contact *

Allergies or Medical Conditions *

If you have any allergies or medical conditions, please share details of these and how you would like us to support you if these occur during our time together.

Your doctor's name and phone number *

Before we begin

What are your expectations from our time together? *

What are the three biggest changes you would like to make in your life? *

These do not have to be specific to the work we’re doing together.

How would you rate your happiness on a scale of 1 to 10?

Selected Value: 1

1 being very unhappy and 10 being extremely happy.

In order to be happier, what do you need? *

In one sentence, how would you describe your previous year? *

Do you have any cultural, religious, or personal safety needs that you would like us to respect or observe during our time together? *

Going Forward

We may assign you some light tasking after your session(s) that will help you achieve your goals. Are you happy to complete this? *

Yes
No

We will play at 100% and commit to being open, honest, and solution-focussed, are you comfortable in doing the same? *

Yes
No

Is there anything you are worried about that you would like us to be aware of? *

Submission of this form indicates that you accept our terms and conditions. We ask that you have a read of these HERE before submitting this form.

Any general comments?

We commit to providing a safe, judgement-free space for you. We respect your privacy and value the trust you are placing in us. We will show up for you 100% and acknowledge that you intend to do the same for yourself.

Thank you for choosing to share your personal growth journey with us.