Success & Life Coach 
Success & Life Coach Client Participation Sign-Up
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First Name | Last Name *
Email *
Address *
Phone number *
Work phone number *
Birth Date *
Marital Status *
Occupation *
Have you ever been treated for an emotional problem? If yes, please explain. *
Have you even been treated for: diabetes, heart disorder, or digestive problems? If so, please explain. *
Are you being treated for any illness and under medical supervision? If so, please explain. *
Have you ever had a coach before? If so, please explain. *
What do you want to accomplish through coaching? *
What are the main three goals you want to accomplish in the next 12 months? *
What are the biggest challenges you are facing right now? *
Any previous efforts to solve this problem? Any results? *
How did you hear about me? *
Required
Please name the person or source on how you heard about me. *
Do you have any fears or phobia? *
I am willing to be coachable and I understand that I am in control of my effort and the results perceived from such. Throughout the working relationship, the coach will engage in direct and personal conversations. The client can count on the coach to be honest and straightforward in asking questions and making requests. The client understands that the power of the coaching relationship can only be granted by the client, and the client agrees to do just that - have the coaching relationship be powerful. If the client believes the coaching is not working as desired, the client will communicate and take action to return the power to the coaching relationship.
Yes, I understand and agree with the statement above
 *
Required
Preferred Certified Success and Life Coach to work with:
 *
Required
Name I like to be called *
Signature | Date *
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