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					                                       Intake Information:
      This is an optional intake form to fill out, but doing so (even in part) will speed up the
       consultation process. It will give me a general sense of who you are and what you would like to
       work on during the coaching sessions. That way, when we speak, we can quickly focus on your
       situation and goals.
      Please fill out this form, and e-mail it to me at BauschCoaching@gmail.com.
      For my own record, I would appreciate learning how you heard about my coaching practice:
           o ___________________________________________________________________



                             Identifying and Contact information
  Note: If you click the “insert” or “Ins” button on your keypad, you can type over the lines. Click the
                                     button again to go back to normal.

Name:__________________________________ Date___________
Home:_____________ Cell phone:___________ Work phone:______________
Fax number________________
Email Address:_________________________
Home Address:_________________________________________
City:_______________ State:_____ Zip code:__________
Date of Birth:___________ Age:______
Emergency Contact:_________________________________________________

Preferred means of communication (phone/e-mail):_______________________________
What is the best time to call?___________
What is your time zone? Pacific___ Mountain___ Central___ Eastern___ Atlantic___
Alaska___ Hawaii___

Is it okay to leave messages from Devon Bausch to all phone numbers and email?____
If not, please specify what you would like me to say in the message:
________________________________________________________________________

What are your preferred coaching times? Please provide a few times in the day
and/or days of the week you have availability.
_________________________________________________________________________
_________________________________________________________________________




                                        Self-Demographics

Please check all that apply:
Married____ Divorced____ Widowed____ Single____ In a Relationship____
Other___________ How long have you been in this category?____________

African American____ Asian____ Caucasian____ Hispanic____ Pacific Islander____ Native
American____ Other______

Heterosexual____ Bi-Sexual____ Homosexual____ Transgender____ Other____________


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                                Education and Profession

GED____ High School____ Some College______ College Degree____ Master's Degree____
Doctoral Degree____ Other______________



                                       Employment

Occupation:___________________
Employed? (Y/N)_____
      Full Time         Part Time                       Per Diem
      On Disabilities   On unemployment                 Retired
Comments:
____________________________________________________________________________
____________________________________________________________________________



                       Family and Spouse/Partner Information

Please list all family members:
Name______________ Relationship______________         Residence____________    Age______
Name______________ Relationship______________         Residence____________    Age______
Name______________ Relationship______________         Residence____________    Age______
Name______________ Relationship______________         Residence____________    Age______
Name______________ Relationship______________         Residence____________    Age______

Are you close to anyone in your family?_____ Whom?______________________________
____________________________________________________________________________
____________________________________________________________________________
Is there anyone in your family that you do not have contact with?_____ Whom?
____________________________________________________________________________
____________________________________________________________________________
Comments:
____________________________________________________________________________
____________________________________________________________________________



                               Friends and Social History

Are you more: Introverted____ Extroverted____ A little of both____

Are you satisfied with the number of friends you have and the substance of the
friendships?(Y/N)_____. If not, please elaborate (i.e. hard to make new friends as an adult,
feel the friendships are somewhat superficial).
____________________________________________________________________________
____________________________________________________________________________




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Who do you rely on for support?
____________________________________________________________________________
____________________________________________________________________________
Comments:
____________________________________________________________________________
____________________________________________________________________________



                                   Health Information

How is your general health (good, fair, poor):____________________________________
If you have any medical/health problems I should be aware of, please describe them.
________________________________________________________________________
____________________________________________________________________________
Are you taking any medications? ________________________________________________
____________________________________________________________________________
Do you have any sleep problems?_____________________________________________
How is your diet and exercise?________________________________________________
Do you have any past or current problems with addictions? _________________________
If so, please describe: _______________________________________________________
_________________________________________________________________________



                                         Therapy

Are you currently seeking therapy? _____ If so, for what purpose?
_________________________________________________________________________
_________________________________________________________________________
Have you ever had any thoughts or plans of suicide/homicide? (Y/N). If yes, please check all
that apply? Thoughts of suicide, homicide, or both:__________. Thoughts of dying, but no
concrete plan____ I had a plan____ history of attempts____ Describe:
_________________________________________________________________________
_________________________________________________________________________
Have you ever received therapy/coaching for any reason?_____ If so, which one?________
What was the most beneficial aspect for you?
_________________________________________________________________________
_________________________________________________________________________
Was there something you would have liked to be different?
_________________________________________________________________________
_________________________________________________________________________




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                               Life Coaching Questionnaire


What are your specific goals and/or intentions for this program?
____________________________________________________________________________
____________________________________________________________________________

What do you think you need from a life coach? A different perspective, brainstorming
strategies, focus/direction, a good listener, assignments/challenges, gentle accountability,
motivation, validation. Other/not sure?
____________________________________________________________________________
____________________________________________________________________________

What part of your life is working best right now (i.e. oneself, family, friends, career, school,
fun/free time, other)? You can list as many/as few as you like.
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

What part of your life is working least right now? Please elaborate with a sentence or two.
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

What are the obstacles that get in the way of achieving your goals?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

What are your values in life/ what is it that you find to be important in life?
____________________________________________________________________________
____________________________________________________________________________

On a scale from 1-10 (10 being the highest), how committed are you to making this program
work for you (it is ok if you are not a 10)?
____________________________________________________________________________


Other information you would like to tell me:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________




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