Executive Coaching Intake Form

I confirm the following:*

I have read, understand, and agree to Dr. RBF's Coaching Agreement

Name*

First Last

Date of Birth*

Employer*

Occupation & Position Title*

Phone*

Email*

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Address*

Street Address City State / Province / Region ZIP / Postal Code Country

What are the positive changes you are wanting to make in your life that I can assist you with?*

The one thing that would have the biggest positive impact on my life when it improves would be...*

If I could create my life exactly as I wanted, this is how it would be...*

Don't hold back! Be sure to include all areas of your life such as career, business, relationships, health, personal development, leisure, family, finances, etc.

My relationships with friends, family, and co-workers are generally...*

My movement practices are...*

My nightly sleep patterns are mostly...*

I eat a healthy, balanced diet (including fresh vegetables & plenty of water)...*

I would classify my current weight as...*

My regular recovery process includes... (please check all that apply)*

What do you do to recharge?*

The following statements apply to me... (please check all that apply)*

Select All
I am currently working with a therapist
I am currently taking medication
I use or have used substances
I am currently restricted physically in some way (injury, recent operation, etc.)
I have experienced mental illness in the past
None of the above

Please add any additional information / comments that will help me serve you better.*

I understand that personal mastery is a process and that I may experience lulls, dips, and frustration as I create new and lasting habits. I agree to do my best and to reach out to my consultant for support and encouragement when I feel like I am not progressing as I anticipated.*

I agree to take full responsibility for my results

I require a tax receipt once I have made payment*

Yes
No

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