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New Client Intake Form

Personal Information:

Full Name *

Date of birth *

Age *

Preferred Pronouns

Gender Identity

Email *

Phone *

Address *

Occupation *

Educational Background *

# of children (if applicable) *

Marital Status *

Married

Single

Divorced

Dating

Current living situation *

Health Conditions/Disabilities (if any) *

Medications (if applicable) *

Goals and Objectives:

What are your primary goals for coaching? *

What specific areas of your life do you want to focus on improving? *

How do you envision your life changing as a result of coaching? *

How do you define success in relation to these goals? *

Are there any short-term or long-term goals you would like to achieve? *

Previous Coaching Experience:

Have you ever participated in coaching before? If yes, please describe your experience. *

What did you find most beneficial in your previous coaching experiences? *

Is there anything you would like to replicate or avoid from your previous coaching experiences? *

Preferences and Expectations:

How do you prefer to receive feedback and support? *

What do you expect from your coach in terms of availability and communication? *

Are there any specific coaching techniques or approaches you resonate with? *

How would you like to measure progress during coaching sessions? *

Are there any cultural, religious, or spiritual considerations that you would like your coach to be aware of? *

Psychological and Emotional History:

Have you ever been diagnosed with a mental health condition? If yes, please specify. *

Are you currently seeing a therapist or mental health professional? *

Yes

Have you experienced any significant life events or traumas that may impact coaching? *

Are there any coping mechanisms or strategies you currently use to manage stress or difficult emotions? *

Lifestyle and Habits:

Describe your typical daily routine. *

Do you engage in regular exercise or physical activity? If yes, please specify. *

What is your diet like? Are there any dietary restrictions or preferences? *

How would you rate your sleep quality and quantity? What would you like to improve? *

Fitness Goals:

What are your primary fitness goals?

Lose Weight

Build Muscle

Improve Cardiovascular Health

Maintenance

Do you have any specific fitness challenges or limitations we should be aware of?

Are you comfortable in the gym setting?

Yes
No
This is new for me
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What type of workouts do you enjoy? (Check all that apply)

Strength Training
Cardio
Bodyweight
HIIT
I like a good mix and a challenge!
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Social Support and Relationships:

Describe your social support network (e.g., family, friends, colleagues). *

Are there any significant relationships in your life that you would like to improve or address during coaching? *

How do you typically handle conflicts or disagreements in relationships? *

Additional Information:

Is there anything else you would like to share about yourself or your situation that may be relevant for coaching? *

Do you have any specific questions or concerns about the coaching process? *

How did you hear about us?

Walk In/Friend

Google

Facebook

Instagram

Other

By submitting this form, you acknowledge that all information provided will be kept confidential between you, the client and Chronic & Iconic Coaching, in accordance with professional coaching ethics and standards, HIPAA regulations and the Privacy Act of 1974.

WHAT PEOPLE ARE SAYING

She is stearn enough to make you understand your own potential without negative reinforcement, and kind enough to make you enjoy the hard work you're putting in to yourself. Using daily affirmations she is truly genuine and one of a kind.

- christin b.

So it’s personal for me. But my experience with Chronic & Iconic Coaching has been nothing short of amazing. We get to the root of all issues and figure out the best outcome for me. That is what makes it special and that is what keeps me coming back for more.

- whitney b.

Coach Andi's personalized approach made me feel truly understood and empowered, providing me with practical tools to enhance my life. I now have a deeper sense of balance and a renewed perspective on wellness—highly recommended!"

- Melissa K.

Contact

andi@chronicandiconiccoaching.com

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