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Name:
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Email Address:
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Date
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Address
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Address
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City
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State
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Zip
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Home Phone
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Cell Phone
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Best time to call
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Is it all right to leave a message at all phone numbers and email? If no, please specify.
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Occupation
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Name of Business
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How long at this employment
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Are you happy at your current employment? If no, please tell me briefly what you would like to be doing differently.
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Date of Birth
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Age
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Other significant dates
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Preferred coaching schedule: (Day and time)
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Emergency contact
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Names and relationships of important people in your life: (spouse/partner, children, friends)
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Pets:
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Education history:
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Health status:
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Do you have any difficulty with sleep? If yes, please explain.
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Are you happy with your current weight/body shape? If no, please briefly tell why?
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Do you have any history or current use of drugs and/or alcohol? If yes, describe:
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Are you seeing a therapist at this time? If yes, briefly describe reason for seeing a therapist.
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Do you take any medications? If yes, what?
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Do you exercise regularly? If yes, what type of exercise and how frequently?
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How many hours of television do you watch daily?
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What do you enjoy doing in your free time?
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Is there a secret passion in your life? If yes, what is it?
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Do you have a Higher Purpose? If so, please briefly describe.
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If you knew you could not fail, what would you attempt to do?
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Is there anything else you would like me to know about you or your circumstances before we begin?
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How did you hear about my coaching services?
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What influenced your decision to work with a transformational life coach?
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Have you ever been coached before? If yes, please describe the experience:
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