Client Record

Title *

Mrs

Miss

First Name *

Family Name *

Address *

Suburb *

Post Code *

Email *

Date Of Birth *

Work Phone

Mobile Phone

Home Phone

So that we can best provide you with the most appropriate Coaching, please answer the following questions… and this is all fully confidential!

Are you under a doctor’s care for depression or any illness? *

Yes

Prescribed

Details of any medication

Medical Practitioner’s name

Do you have a medical condition that could affect the outcome of the coaching?

Yes

If yes, give details

Are you being treated by a Psychologist or a Psychiatrist?

Yes

Have you been treated in the past by a Psychologist or Psychiatrist?

Yes

If yes, Condition being treated

How long have you had the condition?

Practitioner’s Name

Duration of Treatment

Was the treatment successful?

On Average how many of each of the following do you consume per day?

Water

Coffee

Tea

Soft Drinks

Alcoholic Drinks

If you are you a smoker, how many cigarettes/day

Approx cost per year $

Do you take illegal or non-medication drugs

If you are a drug user, give details

Do you think you are overweight? *

Yes

Rate your current energy levels (LOW 1 2 3 4 5 6 7 8 9 10 HIGH) *

Rate your current stress levels (LOW 1 2 3 4 5 6 7 8 9 10 HIGH) *

Declaration. I understand that coaching for most issues consists of a series of consult and 5 sessions. No guarantees are given due to the variety of issues, the client’s personal situation and coaching chosen at the discretion of the coach.

I confirm all the above details are correct.

Name *

Date *

How did you find out about F3-Performance?

Who referred you to F3-Performance?

Please supply if you can the email address of the person who referred you.

Name

Email/Phone

Payment Options

All consultations (for new clients) are to be paid in advance, following sessions and programs are invoiced after the session, please pay immediately.

I invoice directly from my accounting program. Payments are through PayPal or If you prefer to direct deposit, the details are at the base of that invoice.

If the invoice is to be in a company name, please complete this below as it is tax deductible as ‘Professional Development’.

Company Name

The Consultation Session

The F3-Performance coaching consultation allows me to understand your individual situation.

We look at where you want to be, what has been stopping you and what needs to be resolved to allow your potential to be achieved.

The consultation discussion is essential and before any coaching begins to ensure you are aware of exactly what we are going to embark on.

The consultation allows us to really get into what changes are needed for you to become the person that can achieve the dreams and goals you have.

As best as you can, please complete the following questions. This will form the basis of moving forward. This is a result driven coaching program so this may be as much ‘past reflection’ as I need to do for you to move forward.

If you are not sure on what you want to achieve or who you can be, this will evolve out of the discussion. Please do not request changes to be made to this process. It is set this way because it works.

Following the consultation, we will have a great awareness of what is required, and we will discuss a plan of attack, I will recommend this plan based on your required results and your current situation.

In this much space only, give me an idea of… Your life now… dot points is fine!

Where do you want to be in 3 years?

What do you need to change in yourself to become this person in 3 years?

What do you think is stopping you at this point?

What actions, behaviours or habits do you believe are limiting you?

What is the % level of belief you have in achieving this 3- year Target?

Can you find time to spend 30 minutes a day on you?

What have you done prior to seeing me to help you in self- development and personal growth?

Client Record

Client Record Form

The Consultation Session