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CLIENT INTAKE FORM A list of priorities and information about me:

1. I want to improve or expand/extend use of the following skills or develop and create the following components to my professional/personal life:

2. I want to resolve the following challenges or problems:

3. I want to eliminate the following tolerations (what I’m putting up with in my life/business now):

4.I want to accomplish the following measurable or observable results:

5. At this point, I think that I'd like to make these fundamental changes or shifts:

6. What I want and need most from you, as my coach, includes:


By clicking submit below, you agree to the above information.

I understand that I am working with Sally Tankersley, MA. for professional coaching at the agreed fee. I am paying this retainer by check or Pay Pal prior to the beginning of the session. We will have standing scheduled times each week by telephone or, locally, meeting in person, as deemed most useful. Additionally, we may have other interim though limited exchanges by telephone, or email, without additional charge. If there are special circumstances or events that require significant time or an additional session, we can renegotiate rates. All information will be held as confidential unless the client requests otherwise in writing. Professional Coaching is distinctly different than counseling, psychotherapy, and psychoanalysis, and does not deal with the diagnosis or treatment of emotional problems. Sally Tankersley is not acting as a Psychologist or Psychoanalyst in this collaboration. Since Professional Coaching does not constitute medical consultation or treatment, any healthcare insurance does not apply. These fees may be considered deductible business expenses.


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