New Client Intake Form

Transformative Pathways Niagara - Life Coach Jason Dobbie

First Name

Last Name

Age

Date of birth

Gender

Male

Female

Phone *

Email *

Address

State

City

Postal code

Occupation

Marital Status

Single

Divorced

Married

Widowed

Are you currently taking any medications?

Yes

No

If yes, then please indicate the medication name and the purpose below:

Do you have any health condition that you would like to share?

Yes

No

What short term goals would you like to accomplish over the next 3-6 months?

What long term goals would you like to accomplish over the next 1-3 years?

Why do you want to achieve these goals? What is your main motivation?

On a scale of 1-10 how would you rate your current happiness level? Currently, what brings you the greatest happiness in your life?

On a scale of 1-10 how would you rate your current stress level? What is currently causing you stress in your life?

What is the most challenging obstacle you have had to overcome in your life thus far? How did you overcome it?

What would you consider the most significant achievement in life up to this point? How did you achieve it?

What are 3-5 things that you feel are holding you back from achieving your goals?

What does success mean to you, and how do you envision your dream life?

Who are the most important people in your life currently, and what's your relationship with them like?

What steps have you already taken to achieve your goals, and what have been the results so far? What have you learned from this process?

What are your primary motivations and expectations for participating in this coaching relationship? Please elaborate on what you aim to accomplish and which areas of your life you seek to enhance or develop through this coaching journey?

Please indicate your preferred method of communication for correspondence between sessions if multiple coaching sessions are scheduled?

Email
Telegram App
Messenger App
Not Required
Other
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Please provide several days and times that you will be available for coaching sessions, listing those that work best for you.

AGREEMENT\REMINDERS

I understand that all information I entered in this form will be considered strictly confidential.

The data gathered from this form will only be used as a basis for the type of coaching the client will need.

I understand that in order to be successful, it is vital to follow the plan agreed by both the life coach and the client.

Choose Your Coaching Package - All pricing is inclusive of taxes.

Sell Products *

Four Coaching Sessions

You will be coached for four one-hour sessions over the course of six weeks.

CA$800

Eight Coaching Sessions

You will be coached for eight one-hour sessions over the course of ten weeks.

CA$1400

Twelve Coaching Sessions

You will be coached for twelve one-hour sessions over the course of sixteen weeks.

CA$1800

*100% secure & safe payments*

Please indicate your preference for meeting

Virtual
In-Person
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