TREFOIL THERAPIES 
Tel
and Fax: (480) 577-4983
Email: trefoiltherapies@live.com
Website:
http://www.trefoiltherapies.com/
CLIENT - CONFIDENTIAL INFORMATION
We welcome you as a client and are excited to be in
partnership with you in your personal and professional growth. Please, complete the following information
to enable us to serve you better, thank you.
Date of First Appointment:
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Name:
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Occupation:
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Business Name:
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Home Address:
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City:
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State: ___________________________Zip Code:
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Business Address:
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City: ________________________________________________________
State: ___________________________Zip Code:
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Preferred Address: ____ home ____ business
Daytime phone:
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Evening phone: __________________________________________
Fax number:
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What is the best time to call? ____________________
Email Address:
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Is it okay to leave messages at all phone numbers
and email? ________ If not, why?
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Preferred means of communication:
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Date of Birth: _________________ Age: ______
Other significant dates:
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Preferred coaching schedule: on (day of week)
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(time of day) ___________
Emergency Contact:
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Names and relationships of important people in your
life: (spouse, children, friends)
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Pets:
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Education:
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Health in general:
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Do you have any sleep problems?
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Do you have any past or current problems with
addictions? ______ If so, describe:
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Do you have any problems with ADD, depression or
anxiety? _______ If so, describe:
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Are you undergoing therapy for anything? _____ If
so, what and with whom:
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Do you take any medications?
________________________ If so, what:
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Are you usually on time or running late?
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How do you like to learn? (auditory, visual,
cerebral, kinesthetic?)
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What do you do to treat yourself special?
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What do you enjoy collecting?
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What is your idea of a perfect vacation?
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What is the most thoughtful gift you have ever
received?
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Do you exercise regularly? __________ If so, how:
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How many hours of television do you watch daily?
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What is your favorite type of music?
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What hobbies or sports do you enjoy?
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What do you do for fun?
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What is your favorite movie?
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What are your favorite types of cuisine?
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What is success to you?
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What do you believe you have to contribute to the
world?
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Is there a secret passion in your life? _______ If
so, what is it?
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What do you believe in? (family, God, self etc.)
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If you knew you could not fail, what would you
attempt to do?
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Other information you want me to know:
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How did you hear about my coaching services?
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What influenced your decision to work with a life
coach?
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Have you ever been coached before? ___________ If
so, please describe the experience:
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Do you have specific goals for the coaching
relationship? If not, what goals might
you now create for yourself?
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What are your significant commitments:
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Describe what your perfect life would look like: ___________________________
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What dreams do you have?
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What dreams have you given up on?
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What part
of your life, career, or business is working best right now?
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What would you like to be your first focus in
coaching?
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What part of your life, career, or business is
working least right now?
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What are the obstacles that are keeping you from
living the life you want to have?
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What are your values in life?
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How do you want me to be as your coach?
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What can I say to you when you are most ‘stuck,’
which will return you to action?
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Disclaimer: The Client agrees that he/she is entering
into coaching understanding that the Client is responsible for his/her own decisions
and results, and is aware that coaching results cannot be guaranteed. The Client also agrees to hold the coach
free from all liability for any actions or results for adverse situations
created as a direct or indirect result of a referral or other advice given by
the Coach.
______________ Client
Initials.
Call
Procedure: The Client shall contact the
Coach at the agreed hour. If the Client
fails to make the appointment time, the Client is responsible for the coaching
fee, unless 24-hour notice was given to reschedule the call. The Coach will make every effort to
reschedule with the client.
Client
Signature: _____________________________________ Date:
_________________________
Coach Signature:
_____________________________________ Date: _________________________
Coaching Intake Information for Clients
Confidentiality:
The
Coach and Client recognize that the nature of the coaching relationship
involves the passing of personal and business information that may be highly
confidential. As such, the Coach agrees
that, unless express permission is granted, all coaching calls and conversation
and written communications remain completely confidential between the Coach and
Client, except when prohibited by law.
How to Get the Most Out of Your Coaching
It
is important to both of us for you to benefit greatly from the time we spend
together each week, and also during the time between our calls. This brief explanatory template is used to
maximize our mutual understanding of where you are and where you want to go,
and to help you to know what to expect from Coaching.
Success Action #1:
Make a list of What You Value, What You Love, and What You Really
Want in Life.
Coaching
works best when you have clear goals that are in alignment with your needs and
values. If you’re unclear about any of
these, we can discuss them during our sessions.
Success Action #2:
Get to Know Yourself in New Ways.
Working
with a Coach is a healthy way to grow.
Most Clients hire a Coach to accomplish several specific goals. Coaching is all about being and expressing
your genuine best self. Don’t be
surprised if you discover new parts of your self, or if you find your goals
adjusting themselves, to who you really are, and who you want to be. This discovery process is natural; so you
needn’t rush it, just realize it will likely happen. Accelerated personal and professional growth is the hallmark of
being coached.
Success Action #3:
Your Coach is here to Fully Participate in Our Partnership.
It is Your Coach’s job to:
Listen for many things, such as your assumptions, perceptions and conclusions;
what you are saying in your self talk; evidence of emotional pain the blocks
action; what motivates you and excites you; self doubt, growth you may not be
giving your self credit for, resources you already have available but may not
yet recognize, and much more.
Question – What are your goals; what do you love; what may be frightening you
that limits you from taking action; are being present time oriented; are you
willing to trust your self, have courage, and take action; how do you see your
self moving forward in this goal; what inner work must you do to dare to be your
real self consistently in your life, how can we best support you now, and
much more.
Design – Your Coach assists you in defining your personal and a professional
goal in alignment with your needs, values and your genuine self, assists you in
creating strategies, discovering resources, and taking action confidently.
Forwarding Action – A Coach is an equal, not an expert or an authority. A Coach makes requests, offers suggestions,
advice and options, and shares intuitive hunches, which may
be
helpful in facilitating your ongoing forward momentum. Your Coach is an equal partner in designing
your action plan. When your Coach makes
a recommendation for action, you always have the power to stop and renegotiate
your action strategy.
Strengthening and Heartening – It is your Coach’s job to cheer you on; to see
your strengths and to tell you about them; to help you to overcome self doubt,
and accept your self as the person of strength and competence that your really
are; to be the emotional bridge who holds the space for you to dare to risk and
change.
Dream Stretcher – It is your Coach’s job to help you stretch yourself toward your
dreams, to think bigger, to go farther, to be committed, to grow and achieve
more than you’ve dared to imagine.
Staying in Present Time – Your Coach will help you remember that our power
is always in the present moment. In
order to be in the present, it is necessary to have a certain detachment to
outcome. Rather than attach fixedly to
a specific outcome we desire, it is more effective to remain flexible and open,
while we are making progress. In
present time, we always have the power of choice.
Telling the Truth – It is your Coach’s job to tell the truth 100% of the time, from a
viewpoint of compassion and an intention of your well being. Occasionally, this may take the form of
confronting you with a truth that you may prefer to avoid or deny. Your Coach offers you a mirror that has no
judgments attached.
Developing Self Trust – Your Coach assists you in seeing your self as a
resource you can trust and depend on; knowing that you can trust your self, and
reach out to others in collaboration is strength. Becoming dependent on your Coach is not what Coaching is about.
Success Action #4: It is
Your Job to Participate Fully in Our Partnership
Make A Commitment – Fully invest your self in this opportunity for accelerated growth and
accomplishment. Show up for your
coaching call or session on time and fully be there, ready to solve, reflect,
strategize, and celebrate.
Fee
– Keep our partnership clear of undue distractions by paying your coaching fee
on time, as agreed.
Requested Information – Allow yourself enough time to prepare before each
session, allowing time for thought and reflection. Send all request information to Your Coach in plenty of time so
that the Coach also has time reflect.
Self Nurture – We all are more energetic, able to cope, and are inspired when our own
needs are being met. Make a commitment
to nurturing your self and your well being beginning with your first Coaching
session and on out into your future. If
you want to work on expanding your ideas of self-nurture and getting your need
met, let’s discuss it.
Reduce Clutter – Be willing to reduce the clutter in your environment and in your life
that stands in the way of your progress toward your life and your self, as you
would like them to be; Feng Shui advice is also available. Though change can sometimes feel
challenging, your Coach is here to help you smooth the way.
Be Honest with Your Self and Your Coach 100% of the time. The Coach wants to hear everything you wish to express. Compliments and referrals are happily
received, and please, if you ever feel any dissatisfaction in your coaching,
speak up. This will keep the
partnership strong. Partners
communicate with respect as equals and trust each other’s intentions of well being
toward one another. All of your
input is welcome.
Take Action - When you agree to take action, do your best to complete it. If you are having problems that are holding
you back, feel free to email me and we can discuss it via email or in a brief coaching
call during the week.