CLIENT INTAKE FORM
For participation in coaching and/or mentoring services.
Your privacy is important to us, and we want to communicate with our customers in a way which has their consent, and which is in line with both US privacy laws and EU GDRP compliant on data protection. As a result of a change in EU law, we now need your consent to how we contact you. Please fill in the contact details you want us to use to communicate with you:
2 .
Client Information
Full Name
Company
Address
Address2
City/Town
State/Province
ZIP/Postal Code
Country
Country Code | Office Phone
3 .
Additional Contact Details
Cell Phone: +# (###) ###-####
Home Phone: +# (###) ###-####
Fax number: +# (###) ###-####
Personal Email:
By signing this form, you are confirming that you are consenting to the Leatherneck Tech Inc., holding and processing your personal data for the following purposes (please tick the boxes where you grant consent):
5 .
I consent to the Leatherneck Tech, Inc., contacting me by
6 .
Employment Information
Occupation
Employer
7 .
Personal Information
Birth Date: mm/dd/yyyy
Marital Status: m / s / d / sp
No. of Children
Spouse's Name
Spouse's Birth Date: mm/dd/yyyy
8 .
Important Dates in Your Life
To add a paragraph, press SHIFT + ENTER
9 .
Names and Ages of Children
To add a paragraph, press SHIFT + ENTER
(I collect this information in order to form a full and complete picture of my clientele and all the people and activities that impact their lives and decision-making processes. I consider this data highly confidential and will treat it accordingly).
11 .
What do you expect to get out of these coaching sessions?
To add a paragraph, press SHIFT + ENTER
12 .
Tell me something about yourself that you think I should know to coach you better?
To add a paragraph, press SHIFT + ENTER
Briefly share your overall business and life goals.
14 .
Where do you see yourself in...
One Year:
Five Years:
Ten Years:
In addition to all of the above, I grant permission to Leatherneck Tech Inc., to use my personal information
16 .
In addition to all of the above, I grant permission to Leatherneck Tech Inc., to use my personal information...
17 .
Signed (by typing your name, you are legally certifying everything is true and answered to the best of your ability.
18 .
Date:
Thank you! For completing this survay, follow this link to get your free eBiz Card (no strings attached): http://getcard.freebizcard.me/application/j7PfvcjalS/free-signup
To read a copy of our coaching agreement, you may download a copy from the following url: https://s3.amazonaws.com/Leathernecktech/Files/Coaching+Agreement.pdf