Resilient Leadership Through Cancer

Cancer Coaching Intake Form

Thank you for your interest in working with Deb Krier. The information you provide is confidential. It's important to answer as honestly as possible in order for us to create the best coaching plan.

This is a very detailed form and may take some time to complete. At the bottom, there is an option to "Save and Resume Later". You'll receive a link via email to continue working on it.

Name
Mailing Address
Preferred Method of Contact

Personal Information

Date of Birth
Marital Status
Emergency Contact Name

Your Cancer Diagnosis

This information helps us to personalize your coaching experience.
What types of treatment did you receive, or plan to receive?
Select all that apply.
Are you currently receiving treatment?

Current Lifestyle

For a business owner or executive, a cancer journey brings a unique set of challenges — balancing leadership, operations, and personal well-being. The pressure to maintain business success while navigating treatment can feel overwhelming.
What is your level of stress on a typical day?
On average, how many hours of sleep do you get each night?
On a scale of 0 to 5, how would you rate your overall level of satisfaction with your level of exercise/movement?
On a scale of 0 to 5, how do you feel about your schedule and time management?
On average, excluding weekends, how many hours per day do you spend working?
Do you often spend time on work-related items on the weekends?
On a scale of 0 to 5, how satisfied are you with your amount of leisure time?
On a scale of 0 to 5, how supported to you feel on this journey by your family and close friends?
On a scale of 0 to 5, how supported to you feel in your business world?

Your Expectations

Together, we will partner on this journey. You - the client - sets the agenda and the coach supports you in this process. The goals may also change as we progress through this experience. Open communication and honesty is critical to have a successful outcome.
As your strategic advisor, what information and support can I provide that are the most important to you? Select all that apply.
Everyone faces obstacles on their cancer journey. Which of these can you most relate to that we should work on during our coaching sessions? Select all that apply.

Agreement/Reminders

I understand that all information I provided will be considered strictly confidential.

The information gathered from this form will be used as a basis for establishing the goals for our sessions.

I understand that in order for this to be successful, it is vital to follow the plan that is agreed upon by both the client and strategic advisor.

I understand that I will be working with an Integrated Health Coach and will not be treated for any medical or psychiatric conditions.
Save and Resume Later