First Name
Last Name
Date of Birth
Phone Number
Email Address
Preferred Method of Communication
First Name
Last Name
Phone Number
Current Relationship Status
Single
In a Relationship
Engaged
Married
Separated
Divorced
Widowed
Other:
Length of Current/Most Recent Relationship
Number of Previous Long-Term Relationships
What are your primary goals for relationship coaching? (Check all that apply)
Improve communication skills
Resolve conflicts effectively
Strengthen emotional intimacy
Rebuild trust after betrayal
Navigate a breakup or divorce
Prepare for marriage or long-term commitment
Enhance self-awareness and personal growth
Improve dating skills and strategies
Co-parenting support
Other:
What specific outcomes would you like to achieve through coaching?
Preferred Coaching Format
Individual Coaching (One-on-One)
Group Coaching (Small Group Sessions)
Couples Coaching (With Partner)
Other:
Current Relationship Status
Weekly
Bi-Weekly
Monthly
Other:
Preferred Session Length
30 Minutes
60 Minutes
90 Minutes
Other:
Preferred Session Medium
In-Person
Video Call
Phone Call
Hybrid (Mix of In-Person and Virtual)
Other:
Individual Coaching Services
Self-Discovery and Personal Growth
Dating and Relationship Readiness
Healing from Past Relationships
Building Confidence and Self-Esteem
Communication Skills Development
Couples Coaching Services
Conflict Resolution and Problem-Solving
Rebuilding Trust and Intimacy
Pre-Marital Coaching
Navigating Life Transitions Together
Co-Parenting Strategies
Group Coaching Services
Relationship Skills Workshops
Support Groups for Singles
Couples Retreats and Intensives
Mastermind Groups for Personal Growth
Other Services
Customized Coaching Packages
Online Courses and Resources
Follow-Up Support and Check-Ins
Have you participated in relationship coaching or therapy before?
If yes, please describe your experience.
What challenges or obstacles do you anticipate in achieving your relationship goals?
Are there any mental health concerns (e.g., anxiety, depression) that may impact your coaching experience?
If yes, please describe.
Are you currently seeing a therapist or counselor?
If yes, please provide their name and contact information.
Do you have any preferences or requirements regarding your coach (e.g., gender, age, cultural background)?
What is your availability for coaching sessions?
I understand that relationship coaching is not a substitute for therapy or counseling.
I agree to the terms and conditions of the coaching services, including cancellation policies and confidentiality agreements.
I give permission for the coach to take notes and document our sessions for the purpose of providing effective coaching.
I understand that my progress depends on my commitment and active participation in the coaching process.
Client Signature:
Form Template Insight
Please remove this form template section before publishing.
Below is a detailed insight into the Client Intake Form for Relationship Coaching, breaking down its purpose, structure, and the significance of each section. This analysis will help you understand how the form serves both the client and the coach in establishing a productive and tailored coaching relationship.
Purpose of the Client Intake Form
The primary purpose of this form is to:
Detailed Breakdown of Each Section
1. Client Information
Purpose: To collect basic contact details and emergency information.
Insight: This section ensures the coach can communicate effectively with the client and has a point of contact in case of emergencies. It also helps personalize the coaching experience.
2. Relationship Status
Purpose: To understand the client’s current relational context.
Insight: Knowing whether the client is single, in a relationship, or navigating a breakup/divorce helps the coach tailor their approach. For example, a single client may need dating advice, while a married client may require conflict resolution strategies.
3. Coaching Goals
Purpose: To identify the client’s primary objectives for seeking coaching.
Insight: This section helps the coach prioritize areas of focus and design a coaching plan that aligns with the client’s desired outcomes. It also allows the client to reflect on what they truly want to achieve.
4. Coaching Preferences
Purpose: To understand the client’s preferred format, frequency, and medium for coaching sessions.
Insight: This ensures the coaching process is convenient and comfortable for the client, increasing their likelihood of commitment and success. For example, some clients may prefer virtual sessions due to time constraints, while others may value in-person interactions.
5. Services Offered
Purpose: To provide a clear overview of available coaching options and allow the client to choose what resonates with them.
Insight: This section educates the client about the range of services available, helping them make an informed decision. It also allows the coach to highlight specialized areas of expertise.
6. Client Suitability Assessment
Purpose: To evaluate the client’s readiness for coaching and identify any potential barriers to success.
Insight: This section is critical for ensuring the client is a good fit for coaching. For example, if a client is dealing with severe mental health issues, they may benefit more from therapy before engaging in coaching. It also helps the coach understand the client’s history and any past experiences with coaching or therapy.
7. Consent and Agreement
Purpose: To establish clear boundaries, expectations, and legal agreements.
Insight: This section protects both the client and the coach by ensuring mutual understanding of the coaching process, confidentiality, and the client’s commitment to active participation. It also clarifies that coaching is not a substitute for therapy.
8. Signature
Purpose: To formalize the client’s agreement to the terms and conditions.
Insight: This adds a layer of professionalism and accountability, ensuring both parties are committed to the coaching relationship.
Key Benefits of the Intake Form
How Coaches Can Use the Form Effectively
How Clients Benefit from the Form
Conclusion
This Relationship Coaching Client Intake Form is a comprehensive tool that serves as the foundation for a successful coaching relationship. It ensures the coach has all the necessary information to provide effective support while empowering the client to take ownership of their personal and relational growth. By addressing both practical and emotional aspects, the form sets the stage for meaningful and transformative coaching experiences.
To configure an element, select it on the form.