Confidential Coaching Intake Form

Icebergology™ Coaching Academy

Welcome! The purpose of this confidential questionnaire is to gain a comprehensive understanding of your background, aspirations, and current situation. Please allow approximately 45-75 minutes to complete this form thoughtfully. Completing these questions accurately will help us make the most of our coaching journey together. Your completed form can be uploaded to our secure online folder.

Your responses will be kept strictly confidential and used solely for the purpose of our coaching engagement.

When saving your completed form, please name the file: YourLastName_YourFirstName_Intake.pdf (e.g., Doe_John_Intake.pdf)

Important: This form does not save automatically online. If you close your browser window before completing and saving/uploading the form, your entered information may be lost.

Please complete the following pages thoughtfully. Feel free to skip any questions that don't seem relevant to you or your goals for coaching.

Section 1: Personal Information

Date:

First Name:

Last Name:

Address:

City:

State:

Zip:

Phone (Day):

Phone (Evening):

Email Address:

Date of Birth:

Age:

Occupation:

Who referred you?

With whom are you currently living? (List names/relationships)

Current Residence: (e.g., House, Apartment, Other)

If married, anniversary date:

Number of times married:

If married/partnered, partner's name, age, occupation:

Section 2: Background & Focus Areas

1. Role of religion, faith, and/or spirituality in your life:

A. In childhood:

B. Currently:

2. Coaching Focus:

A. Please describe the main challenges or areas you'd like to focus on in coaching, and how long they've been present:

B. Briefly describe the history and development of these areas (from onset to present):

C. On the scale below please indicate the current impact of these challenges/areas:

D. Have you previously consulted with coaches, counselors, or other professionals about these areas? If yes, please briefly describe:

E. Are you currently taking any medication that might be relevant to our coaching work (e.g., affecting energy, mood, focus)? If yes, please list:

Section 3: Personal History & Well-being

A. Date of Birth:

B. Place of Birth:

D. Health during childhood (list significant illnesses/conditions):

E. Health during adolescence (list significant illnesses/conditions):

F. Height:

G. Weight:

H. Surgical operations (list type and age at the time):

I. Significant accidents (list type and age at the time):

J. List your five main current concerns or fears:

M. Present interests, hobbies, and activities:

N. How is most of your free time occupied?

O. Highest level of education completed:

P. Scholastic abilities: strengths and weaknesses:

Q. Were you ever bullied or severely teased?

R. Do you make friends easily?

S. Do you maintain friendships?

Section 4: Career & Finances

A. What is your current occupation/work?

B. Previous jobs/roles:

C. Are you satisfied with your present work? (If not, please explain):

D. Does your work provide adequate income?

E. Do you typically experience financial stress?

F. Ambitions/Goals:

Past:

Present:

Section 5: Relationships & Sexuality

Please feel free to skip any questions in this section you are not comfortable answering or feel are not relevant to our coaching work.

A. Parental attitudes toward sex (e.g., was there sex instruction or discussion in the home?):

B. When and how did you first learn about sex?

C. When did you first become aware of your own sexual impulses?

D. Did you ever experience anxieties or guilt feelings arising out of sex or masturbation? If yes, please explain briefly:

E. Please list any relevant information regarding your first or subsequent sexual experiences:

F. Is your present sex life satisfactory? (If not, please explain):

G. Are you sexually inhibited in any way?

Section 6: Menstrual History (If Relevant)

Please feel free to skip any questions in this section you are not comfortable answering, feel are not relevant, or if this section does not apply to you.

Age of first period?

Were you informed beforehand?

Regularity?

Pain?

Typical Duration:

Date of last period:

Do your periods affect your moods or energy levels?

Section 7: Marriage/Partnership History

Answer if applicable.

How long did you know your current spouse/partner before engagement/commitment?

How long have you been married/in a committed partnership?

Spouse's/Partner's Age:

Spouse's/Partner's Occupation:

A. Describe your spouse's/partner's personality:

B. In what areas are you and your spouse/partner compatible?

C. In what areas are you and your spouse/partner incompatible or experience challenges?

D. How do you get along with your in-laws (if applicable)?

E. How many children do you have? Please list their gender and age(s):

F. Do any of your children present special challenges or concerns?

G. Comments about any previous marriage(s)/significant long-term relationships:

H. Any history of miscarriages or abortions?

Section 8: Family Background

A. Father:

Living Deceased

If deceased, your age at the time:

Cause of death:

If alive, father's present age:

Occupation:

Health:

B. Mother:

Living Deceased

If deceased, your age at the time:

Cause of death:

If alive, mother's present age:

Occupation:

Health:

C. Siblings:

Number of brothers:Ages:

Number of sisters:Ages:

D. Your birth order (e.g., oldest, second of four, only child):

E. Relationship with siblings:

Past:

Present:

F. Describe your father's personality and his attitude toward you (past and present):

G. Describe your mother's personality and her attitude toward you (past and present):

H. How were you typically disciplined or guided by your parents as a child?

I. Describe your home atmosphere growing up (e.g., compatibility between parents, parent-child relationships):

J. Were you able to confide in your parents?

K. Did your parents understand you?

L. Basically, did you feel loved and respected by your parents?

M. If you have a step-parent, what was your age when your parent remarried?

N. Describe your religious/spiritual upbringing:

O. If you were not raised by your parents, who raised you, and between what ages?

P. Has anyone (parents, relatives, friends) significantly interfered in your major life decisions (marriage, occupation, etc.)?

Q. Who are the most important people in your life currently?

R. Does any immediate family member struggle with alcoholism, significant mental health challenges, or other conditions relevant to your understanding of your family system?

S. Are there any other family members about whom information regarding illness, challenges, etc., is relevant?

T. Recount any significant fearful or distressing experiences not previously mentioned:

U. What do you hope to achieve through this coaching engagement? Please list your main goals:

V. List any situations, activities, or places that generally make you feel calm or relaxed:

W. Have you ever gotten into trouble because of anger or frustration?

X. Please add any other information not covered by this questionnaire that you feel would be helpful for me to know to support you better:

Section 9: Self-Perception

Please complete the following sentence fragments.

A. I am a person who...

B. All my life...

C. Ever since I was a child...

D. One of the things I feel proud of is...

E. It's hard for me to admit...

F. One of the things I haven't forgiven is...

G. One of the things I feel guilty about is...

H. If I didn't have to worry about my image...

I. One of the ways people hurt me is...

J. Mother was always...

K. What I needed from mother and didn't get was...

L. Father was always...

M. What I wanted from my father and didn't get was...

N. If I weren't afraid to be myself, I might...

O. One of the things I'm angry about is...

P. What I need and have never received from a woman (or man/partner) is...

Q. The challenging thing about growing up was/is...

R. One of the ways I could help myself but don't is...

Section 10: Perspectives

Briefly describe how you think the following people might describe you.

A. Yourself:

B. Your spouse/partner (if applicable):

C. Your best friend:

D. Someone who dislikes you or finds you challenging:

Section 11: Desired Changes & Perspectives

A. What aspects of your current behavior or habits would you like to change?

B. What feelings do you wish to experience more of? What feelings do you wish to experience less of?

C. What do you consider your most unhelpful or limiting thought pattern?

D. List any interpersonal relationships that currently bring you:

Joy/Support:

Grief/Stress:

E. In a few words, what are your expectations of the coaching process?

Prayer is welcome here.

How might I pray for you regarding this coaching journey?