Intake form (EN) – Potential Activation

intake form

This is where you find your intake form. The purpose of this form is to become conscious of, get a clearer picture of your situation, and use this information during your coaching program.

Name

Last name

Street

House number

Postal code

City

Date of birth

Marital status

Gender

Phone number

Hobbies

Highest education

Current employer

Current job and since when

How did you find Potential Activation?

What would you like help with?

After completing the coaching program, what do you want to have changed most of all?

What do you expect from your coach? (And if you have any questions, ask them here)

What do you like about yourself?

What do you like less about yourself?

On a scale of 1-10, how much would you like to change this behavior?

How would you score the overall quality of your life at this moment? (on a scale of 1-10)

If you take any medication for any psychological condition, would you please mention that here

I don't take any medication I take medication

Comments / other relevant information

Having life goals or an image of what you want to achieve in 3 to 5 years determines how driven you are to achieve that life goal. The clearer you are about this, the more driven you will be and of course the reverse. Write below what your life will look like in five years. Describe both your private and work situation. Write down what you will have achieved and what most important personal qualities you have used to achieve this. [Minimum 10 and maximum 30 lines.]

Would you like to receive Potential Activation's monthly newsletter?

Yes, please! No thank you.

The information in this form is confidential and will only be used by us as coaches. In accordance with the NOBCO code of ethics, we will not share this information with anyone else.

intake form

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