Coaching Intake Form | Jordyn Manning, PMHNP-BC

Section 1 of 7

About You

Let's start with the basics so I can get to know you before we meet.

First Name *

Last Name *

Email Address *

Age

Occupation

How Did You Hear About Me?

Step 1 of 7

Section 2 of 7

Your Goals & Intentions

Understanding what you want to accomplish helps me design every session around your specific outcomes.

What is the #1 thing you most want to accomplish through our coaching? *

What area(s) of your life does this primarily relate to? (Check all that apply)

Health & physical wellbeing Mental & emotional health Relationships & communication Career & professional growth Finances & abundance mindset Purpose, identity & personal growth Confidence & self-worth Business / entrepreneurship

What would achieving this goal mean for your daily life?

Is there a specific timeframe or deadline attached to this goal?

Step 2 of 7

Section 3 of 7

Current Situation & Challenges

Help me understand where you are right now — no judgment, just clarity.

In your own words, describe what's going on in your life right now that led you to seek coaching. *

What is your biggest challenge or obstacle right now?

How long have you been dealing with this challenge?

Less than 3 months 3–6 months 6–12 months 1–3 years More than 3 years

What have you already tried to address this? What worked, and what didn't?

Step 3 of 7

Section 4 of 7

Symptoms & Patterns

This section helps me understand how challenges are showing up in your body, mind, and daily behavior.

If you checked any physical symptoms, please describe them:

Are there recurring patterns or cycles you notice in yourself?

On a scale of 1–10, how much is this impacting your quality of life right now?

Barely noticeableSeverely impacting life

Step 4 of 7

Section 5 of 7

Mindset & Beliefs

Our inner dialogue shapes everything. This section helps me understand what's happening beneath the surface.

What do you believe about yourself that might be holding you back?

How would you describe your relationship with yourself right now?

Very critical — I'm my own harshest judge Somewhat critical — I struggle with self-compassion Neutral — I don't think about it much Mostly positive — I generally like who I am Very positive — I have a strong sense of self

What do you believe you're most capable of achieving?

What fears come up when you imagine actually reaching your goals?

How open are you to challenging beliefs that may no longer serve you?

Not at all readyFully ready

Step 5 of 7

Section 6 of 7

Support, Lifestyle & History

Context about your life helps me tailor a plan that's realistic for your situation.

What does your current support system look like?

Are you currently working with any other practitioners?

Yes — I'll describe below No, coaching is my only support right now

If yes, describe who you're working with and what for:

What does a typical week look like for you?

Have you worked with a coach before?

Yes — it was very helpful Yes — it was somewhat helpful Yes — it didn't work out for me No, this is my first time

If you've been coached before, what worked well and what didn't?

On a scale of 1–10, how committed are you to doing the work between sessions?

I'll show up but that's itAll in — fully committed

Step 6 of 7

Section 7 of 7

Coaching Preferences & Final Thoughts

Help me show up for you in the way that works best.

How do you prefer to be coached? (Check all that apply)

Direct and no-nonsense — tell me what I need to hear Supportive and encouraging — I need to feel safe first Practical with actionable steps every session Deep dives — I want to understand the root cause Accountability check-ins between sessions Flexible — let me follow my energy

What does the ideal outcome of our first 4 sessions look like?

Is there anything you're nervous or hesitant about coming into this coaching relationship?

Is there anything you'd like me to know about you that we haven't covered?

One word that describes how you're feeling right now, starting this process:

Step 7 of 7

Client Intake Form