WNY Life Coaching Center: Client Data Form
5500 Main Street Suite 313
Williamsville, NY 14221
716-560-6552
CLIENT DATA FORM
DATE: ______________________________________________________
NAME: _____________________________________________________
ADDRESS____________________________________________________________________________________
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BUSINESS ADDRESS________________________________________________________________________
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HOME Phone_______________________________________ CELL__________________________________
EMAIL: _______________________________________________________________________________________
Ok to leave message everywhere? ____________ If not, please instruct_____________________
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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.)
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Emergency Contact_______________________________________________________________________
Other information you want me to know about-_________________________________________
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How did you hear about my coaching Services?
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What influence your decision to work with a coach_____________________________________
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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?
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What are your significant commitments?
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What would your perfect life look like?
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What are your dreams?
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What dreams have you given up on?
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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?
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What are your values?
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What stops you from having the life you want to have?
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