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WNY LIFE COACHING CENTER

Evidence-Based Coaching  ~ Energy Healing  ~Min​d-Body Medicine

WNY Life Coaching Center: Client Data Form

5500 Main Street Suite 313

Williamsville, NY 14221

716-560-6552

CLIENT DATA FORM

DATE: ______________________________________________________

NAME: _____________________________________________________

ADDRESS____________________________________________________________________________________

_______________________________________________________________________________________________

BUSINESS ADDRESS________________________________________________________________________

______________________________________________________________________________________________

HOME Phone_______________________________________ CELL__________________________________

EMAIL: _______________________________________________________________________________________

Ok to leave message everywhere? ____________ If not, please instruct_____________________

________________________________________________________________________________________________

Preferred method of communication: _____________________________________________________

Occupation:__________________________________________________________________________________

Date of Birth_________________________________________ Age________________________M or F

Other Significant Dates__________________________________________________________________

Preferred Coaching Schedule:

Day of week______________________________________ Time/s__________________________________

Please circle All Acceptable coaching methods:

In person / Skype / Phone Calls/ E-mail

Most Preferable:

In persons/ Skype/ Phone Calls/ E-mails

Name of important people in your life (spouse, partner, children, parents friends, workers, boss, teachers etc.)

________________________________________________________________________________________________

_______________________________________________________________________________________________

_________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

Emergency Contact_______________________________________________________________________

Other information you want me to know about-_________________________________________

________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

How did you hear about my coaching Services?

__________________________________________________________________________________

What influence your decision to work with a coach_____________________________________

______________________________________________________________________________________________

_______________________________________________________________________________________________

WNY LIFE COACHING CENTER

5500 Main Street Suite 313

Williamsville, NY 14221

716-560-6552

Have you ever been coached? Please describe if so

Do you have specific goals for the coaching relationship? If not, what goals might you now create?

_______________________________________________________________________________________________

______________________________________________________________________________________________

What are your significant commitments?

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_______________________________________________________________________________________________

What would your perfect life look like?

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

What are your dreams?

______________________________________________________________________________________________

____________________________________________________________________________________________

What dreams have you given up on?

________________________________________________________________________________________________

________________________________________________________________________________________________

Where do you want to focus first?

What parts of your life are working best now?

What parts of your life are working least well?

________________________________________________________________________________________________

__________________________________________________________________________________________________

_______________________________________________________________________________________________

What are your values?

______________________________________________________________________________________________________________

__________________________________________________________________________________

_________________________________________________________________________________________________

What stops you from having the life you want to have?

______________________________________________________________________________________________

________________________________________________________________________________________________