ALL CLIENT INFORMATION IS TREATED AS PRIVATE AND CONFIDENTIAL.

Thank you for taking the time to fill out the below questionnaire. 

Date:
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Name:*

Address:*
Phone:

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Mobile Phone:*

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E-mail:*
Date of birth:*
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Sex:*

Marital/Relationship Status:

Number of children:
Occupation*
Specific information about family, childhood, marriage, relationships, ,religion, sexuality, work, alcohol, substance abuse, habits etc that YOU believe will be pertinent to the coaching/mentoring process and will be beneficial to a positive outcome:
How would you describe your Sleep / Relaxation?*

How did you hear about me?
Have you ever participated in a coaching/mentoring relationship before?*

If you answered 'YES' to the above, in what circumstances and capacity? Also, if you did take part in a coaching/mentoring process in the past, what did you find beneficial and what was not conducive to what you were previously trying to achieve?
 MEDICAL HISTORY
Please let us know by ticking the box, if you have been under the care of a doctor in the last 12 months for any of the following:

If you ticked either of the above please provide us with more details:

If you have sought medical help for emotional issues, we may (and only with your permission), seek to contact your GP/Medical Professional. This being the case and if you give us permission to do so, please the details below

Doctors name:

Doctors Surgery Address:
Details of any prolonged illness:
Are you currently taking medication?*

If you answered 'YES' to the above, please provide details:
REASONS FOR SEEKING COACHING AND MENTORING?
AIMS AND OBJECTIVES OF COACHING/MENTORING

QUESTIONS YOU MAY HAVE:

Question 1
Question 2
Question 2(1)
  • I hereby confirm that, to the best of my knowledge the information I have given is correct.
  • I am aware that I am entering into a coaching/mentoring contract where my commitment and collaboration is vital to attaining a successful outcome. This includes completing tasks and exercises assigned and of which I cannot provide any tangible or reasonable objections.
  • I acknowledge that all client, coaching and mentoring content is strictly confidential.
  • I understand that visiting a life/executive/business coach or mentor does not replace medical advice or treatment. I can confirm that the coach/mentor has not advised in any form against seeking or continuing medical or other professional advice or treatment, nor have they advised on the cessation or reduction of prescribed medication.
  • I have denoted on the form above if I have given permission for written contact between the coach and my gp if agreed it may be relevant and pertinent to the work.
  • No audio/video recording of the session may be allowed. I can however, request a video recording be made of the session for mutual protection and held securely for future reference. 
  • I am happy to pay in advance to secure the initial and subsequent appointments, with the understanding that any questions raised in the relevant section within the above questionnaire will have been responded to in writing prior to the first consultation.
By Signing Below I acknowledge and agree to ALL OF THE ABOVE:*