Samantha Shakira Clarke

01

Personal information

First name *

Last name *

Preferred name

Pronouns

Date of birth

Email *

Phone number *

City / country and time zone *

Occupation

EMERGENCY CONTACT

Emergency contact name *

Used only if an urgent safety concern arises during a session.

Relationship to you *

Emergency contact phone number, including country code *

02

The good stuff

Where would you like the main focus of our sessions to be? *

Personal development and wellbeing

Professional development and leadership

A blend of personal and professional development

Not sure yet, I would like to explore this together

What brings you to coaching at this point in your life? *

What are the three main things you would like to work on together?

Goal 1 *

Goal 2

Goal 3

What would meaningful progress look or feel like for you?

How do stress or overwhelm tend to show up for you, emotionally, physically or in your relationships?

What activities, people or experiences bring you joy or help you feel more like yourself?

Are there approaches or activities you do not enjoy, or would prefer to avoid? What would you like me to understand about that?

03

Your experience & personal context

Have you worked with a coach before? If so, what did you like, what did not suit you, and what helped most?

Have you explored counselling, somatic therapy, meditation or other forms of personal support? Share anything about those experiences that would help us work together.

Are you currently working with any other professionals, such as a counsellor, therapist, physiotherapist or medical practitioner, that you would like me to know about?

Are there any past emotional, psychological, physical or spiritual traumas or difficult experiences that you feel may be affecting your life now?

Please share only what feels safe and comfortable. You do not need to describe what happened. You can mention its current impact, anything you would like me to be mindful of, or discuss it in session instead.

Are there any triggers, boundaries, cultural considerations or access needs that would help you feel comfortable and supported in our sessions?

04

How you would like to work

If you selected Other, what would you like to explore?

Would you like gentle movement to be part of our sessions? *

Yes

Maybe, I would like to discuss it

No, not at this stage

05

Your comfort & wellbeing

These questions help me adapt any optional movement, breathing or body-based practices to you. You can choose to discuss the details in session.

Are there any injuries, ongoing pain, health conditions, pregnancy-related considerations, dizziness, or medication effects that may be relevant to participating comfortably in gentle movement or breathing practices? *

No

Yes

Unsure

Prefer to discuss in session

If relevant, what would you like me to know?

Only share what is relevant to participation. You do not need to provide a full medical history or medication list.

Has a healthcare professional advised you to avoid or modify any movement or breathing practices? *

No

Yes

Unsure

Prefer to discuss in session

If relevant, what guidance or restrictions should we take into account?

If anything needs clarification, we will discuss it before including the relevant practice. Where medical guidance is needed, that practice will wait until appropriate advice has been obtained.

06

Anything else

Is there anything else you would like me to know before we begin?

07

Acknowledgements & signature

Please read and tick each statement before signing. *

I understand our 24-hour cancellation policy. Sessions cancelled within 24 hours of the scheduled time will be forfeited.

I understand that coaching supports personal growth and is not a substitute for medical care, psychotherapy or crisis support.

I understand that movement, breathwork and other practices are optional. I can decline, pause or stop a practice at any time.

I have read the privacy notice and understand how my intake information will be used and stored.

I confirm that the information I have provided is accurate to the best of my knowledge, and I will let Sammy know about relevant changes.

Full name *

Date *

Signature *

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A little about you, so we can begin with care.