PERSONAL INFORMATION
Professional Coaching includes an initial extended evaluation, weekly telephone sessions, and perhaps e-mail, telephone and fax communication. In-person meetings are also available.
Date: ________________ Referred by: __________________________________________
Name: ____________________________________ DOB: ________________ Age: ______
Home Address: ____________________________________________________________
___________________________________________________________________
Occupation: ________________________________________________________________________
Business Name and Address: ________________________________________________________________________
________________________________________________________________________
Home phone: ______________________________ Business Phone: ___________________ Fax line: __________________________________ E-Mail:_________________________ Can LLT Life Coaching leave a message: Yes __ No __
Preferred means of communication: Phone __ Email __ Other: _______________________ Names of important people in your life (spouse, partner, children, friends, etc.): ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________
Other information you want me to know: ________________________________________________________________________ ________________________________________________________________________
ABOUT YOU
1. I want to improve or expand/extend use of the following skills or develop and create the following
components to my professional/personal life:
a)
b)
c)
2. I want to resolve the following challenges or problems:
a)
b)
c)
3. I want to eliminate the following tolerations (what I’m putting up with in my life/business now):
a)
b)
c)
4. I want to accomplish the following measurable or observable results:
a)
b)
c)
5. At this point, I think that I’d like to make these fundamental changes or shifts:
a)
b)
c)
6. What I want and need most from you, as my coach, includes:
a)
b)
c)
7. Also, I want you to know that:
a)
b)
c)
PROFESSIONAL COACHING AGREEMENT
I understand that I am working with Emra Smith for professional coaching at the agreed fee. I am paying this monthly retainer by check or Pay Pal prior to the beginning of the month. We will have standing scheduled times each week by telephone or meeting in person, as deemed most useful. Additionally, we may have other interim though limited exchanges by telephone, email, or for review of faxed material without additional charge. If there are special circumstances or events that require significant time or an additional session, we can renegotiate rates.
All information will be held as confidential unless the client requests otherwise in writing.
Professional Coaching is distinctly different than counseling, psychotherapy, and psychoanalysis, and does not deal with the diagnosis or treatment of emotional problems. Since Professional Coaching does not constitute medical consultation or treatment, any healthcare insurance does not apply. These fees may be considered deductible business expenses.
Signature: _______________________ Date: ___________________