Get Aquainted Relationship

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Ideal Balance Relationship Coaching Intake Form

Personal Information
Name:		Address:
Email::		How often do you check email?
Home Phone:		Work Phone:
Cell Phone:		Age:
Birthdate:		Place of Birth:
Occupation:		Relationship Status:
Partner (s) name (s) (if applicable):		Do you have children?
If kids, names/ages:

Overall Questions
How would you describe your current relationship status?	How would you describe your sexual orientation?

What are the three most important things you’ve learned about yourself, your relationships and/or your sexuality in the past year?	If you could change one thing about your relationships and/or sexuality, what would it be?

What do you feel most confident about in regards to your relationships and sexuality?	What do you feel least confident about in regards to your relationships and sexuality?

What questions do you have about sex or relationships that you would like to have answered?	Describe one to three outcomes you would like to see for yourself from us working together:

What difference would that make in your life?	What questions do you have about working with a coach?