WNY LIFE COACHING CENTER

Power from Within

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?


______________________________________________________________________________________________

________________________________________________________________________________________________