Client Information Form

Personal Information

Please fill out the following form. Be easy with yourself as you answer these questions. For some of the questions you are going to have lots to say while you may leave others blank. This is nothing more than a tool that is going to help us to move forward in the visioning and planning processes. Please feel free to type your information directly into this document.
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Where You Are Now

Please provide a clear description of what is going on in your life. Include recent victories, lessons learned, struggles, failings, repeating patterns, and any other information that you feel is pertinent. You only need to provide information for the areas you want to work on with this program. Feel free to provide information for the areas that we are not going to be working on, but you feel would be useful for me to know. There might be some overlap in some of your answers. You don’t need to repeat yourself.

Self Sabotage

Describe the types of self-sabotaging behaviors you are most prone to use. Please include specific examples. (Ex: never prepare adequately, never perform a certain task because it has to be perfect, once you reach a level of success doing something, to mess it up or take it apart, not knowing where to begin so you simply don’t do anything at all, being your worst critic … always finding fault in everything you do)

Where You Would Like to Go:

If time and money were no object what would the following areas of your life look like one year from now. Please provide as little or much detail as you can think of. Bear in mind that we are going to be spending a great deal of time at the beginning of the program fleshing this out, so be easy with yourself if you have a hard time coming up with a vision. As you are doing this section, please also include in parentheses any negative self-talk that comes up with any of these goals. Example: “I would like to lose 40 pounds. (That is never going to happen.) And yes, it is ok if there are multiple lines of self-talk for each goal. That is why we are doing this work. To clear that out.

Hopes and Support

What specific hopes do you have for this program outside of reaching specific goals? What should I know about you, how you work, and how you are best coached in order to be the best support to you.


What other information is important for me to know about you and your situation?
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