Client Intake

Name:

Email Address:

Date:

Address 1:

Address 2:

City:

State:

Zip:

Home Phone:

Cell Phone:

Best time to call:

Is it all right to leave message at all phone numbers and email? If no, please specify.

Occupation:

How long at this employment:

Are you happy at your current employment/ or retirement? If no, please tell me briefly what you would like to be doing differently.

Are you happy with other areas of your life?

Date of Birth:

Age:

Other significant dates:

Preferred coaching schedule (Day and time):

Emergency contact:

Name and relationships of important people in your life (spouse/partner, children, friends):

Pets:

Education history:

What is your current health status?:

Please give a brief history of your health:

Are you currently having any difficulty with sleep? If yes, please explain:

What is your history with sleep?

Do you have any history or current use of drugs and/or alcohol? If yes, please describe:

Are you seeing a therapist at this time? If yes, briefly describe the reason for seeing a therapist.

Do you take any medications, vitamins, herbs or supplements? If yes, what?

Do you exercise regularly? If yes, what type of exercise and how frequently?

What activities nurture you the most?

Is there anything else you would like me to know about you or your circumstances before we begin?

In what ways would you most like to be coached. Please check the options that sound most beneficial.

How did you hear about my coaching services?

Have you ever been coached before? If yes, please describe the your experience.

Thank you for giving this background information. It will provide more context and foundation as we begin to work together. I am looking forward to our first session.