Coaching Intake Form

Please enable JavaScript in your browser to complete this form.

Coaching Intake Form


Please take a few moments to complete this form. It is your opportunity to inform your therapist about yourself, your needs, and your goals, as well as providing necessary information. Please be accurate and specific.

Client Information

Address

Emergency Contact Information

PRESENTING PROBLEM

Selected Value: 0
Have you been in therapy?
Please check all of the symptoms in the following list that you are currently experiencing:

PERSONAL INFORMATION

Self

Military Service:

Parent / Guardian

Military Service:

HEALTH HISTORY

Do you have any current health problems?
Have you been on any medication during the past six months?
Selected Value: 0
Selected Value: 0
Selected Value: 0
Have you ever attempted suicide?
Have you ever been sexually abused?
Have there been any pregnancies that have not gone full term?
Have you ever been hospitalized for major health, psychological, drug, or alcohol problems?
May we thank the person for the referral?

Consent for Treatment

I, the undersigned, have voluntarily applied for and agree to participate in wellness coaching services. The ultimate responsibility of the fees is that of the undersigned/ client or parent /guardian. CLIENTS ARE REQUESTED TO PROVIDE 24 HOUR NOTICE OF CANCELLATION. WITHOUT SUCH NOTICE CLIENTS WILL BE BILLED FOR THE PROFESSIONAL TIME AT THE REGULAR HOURLY or HALF HOUR RATE. Your signature indicates your understanding and acknowledgment of the foregoing information.
Clear Signature

© Copyright 2023 - Lock And Key Wellness. Design by ETUGRAND
To Top

10 Proven Ways to Encourage Healthy Adventure
—Without Compromising on Safety

Teens are wired to seek excitement—it's part of how they grow. In this quick, colorful guide, Jessica Gonzalez (MA, Adolescent & Young Adult Specialist) from Journey Forward Somatic Therapy & Lock and Key Wellness shows you:

Help your teen build confidence, resilience, and self-awareness through healthy thrill-seeking—while keeping safety your top priority.
  • How to understand the teen brain's drive for novelty and risk-taking
  • Structured ways to channel energy into rock climbing, drama clubs, martial arts, and go-kart racing
  • Strategic supervision techniques without hovering
  • Self-assessment questions to teach your teen: "Is this safe? Who's in charge?"
  • How to keep communication open and talk through "close calls" without judgment
  • Red flags that may indicate deeper issues requiring professional support
Something went wrong. Please try again.
Thank you! Your download will start shortly.