Psychic Life Coaching Intake Form

Your success is our #1 priority.

Help us to help you achieve that success by filling out this questionnaire as completely as possible. Enter your information below to begin a Psychic Life Coaching Consultation.

Name: *

Date: *

Home #: *

Work #:

Cell #:

E-mail: *

Height *

Weight *

Age *

Sex *

Marital Status *

Education: *

College Degree *

Major:

Occupation: *

Favorite Hobbies: *

Do you enjoy your work? *

Are you satisfied with your income? *

Are you currently under the care of a physician? *

Do you feel stress (explain)? *

Do you exercise? *

How often? *

What type? *

What worries you most? *

How did you hear about us? *

Please rate your satisfaction with your life in the following areas (1 – worst, 5 – best) : Emotions *

Please rate your satisfaction with your life in the following areas (1 – worst, 5 – best) : Relationships *

Please rate your satisfaction with your life in the following areas (1 – worst, 5 – best) : Sexuality *

Please rate your satisfaction with your life in the following areas (1 – worst, 5 – best) : Body *

Please rate your satisfaction with your life in the following areas (1 – worst, 5 – best) : Work *

Please rate your satisfaction with your life in the following areas (1 – worst, 5 – best) : Money *

Please rate your satisfaction with your life in the following areas (1 – worst, 5 – best) : Spirituality *

What one thing do you want more of in your life right now? *

What one thing do you want less of in your life right now? *

List three things you are tolerating right now in your personal life. *

List three things you are tolerating right now in your work life. *

What’s one thing you would like to achieve but aren’t sure how to do it? *

Listed below are some typical results experienced by coaching clients. Which 3 are most important to you? (direction, focus, accountability, a new perspective, relationship success, strategies, better finances, motivation, new challenges, other-please list) *

How well do you keep your commitments when taking advice or working with someone towards your goals? (very, moderately, not too much) *

Do you have any specific goals and/or intentions for this program? *

How committed are you to making this program work for you? *

What is the most important element in deciding to use our services (select one): *

Effectiveness (your results)

Time (how fast you get results)

Service (how we respond to your needs)

Affordable (what we charge)

Appointments are available between 3-10pm (CST) Monday-Friday. Are there any particular days/times that work better for you? If so, please list the days/times that work best. *

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