Client Intake Assessment
CLIENT NAME:
DATE OF BIRTH:
OCCUPATION:
CELL NO.:
EMAIL ADDRESS:
PHYSICAL ADDRESS:
A Few Questions
1.What do you do for a living (work)?
2. What is one thing that you want to achieve in the next 90 days (personal or professional)?
3. What does success in your life mean to you?
4. Where are you in your journey to achieving this success?
5. What do you think that you still need to do to achieve success?
6. What area/s do you feel that you need help in?
7. What are your goals & expectations of our 12 week "Own your Power" program?
8. On a scale of 1 - 10, what is your level of commitment to taking action from this program? ( 1= not committed and 10 = fully committed)
SUBMIT
Client Intake Assessment
CLIENT NAME:
DATE OF BIRTH:
OCCUPATION:
CELL NO.:
EMAIL ADDRESS:
PHYSICAL ADDRESS:
A Few Questions
1.What do you do for a living (work)?
2. What is one thing that you want to achieve in the next 90 days (personal or professional)?
3. What does success in your life mean to you?
4. Where are you in your journey to achieving this success?
5. What do you think that you still need to do to achieve success?
6. What area/s do you feel that you need help in?
7. What are your goals & expectations of our 12 week "Own your Power" program?
8. On a scale of 1 - 10, what is your level of commitment to taking action from this program? ( 1= not committed and 10 = fully committed)
SUBMIT
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