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

Today’s Date*

Name

Phone

Email

Social Security

Date of Birth *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Emergency Contact Information

Name

Phone

PRESENTING PROBLEM

Please state in your own words the nature of your main concern(s).

On the scale below, please circle the number indicating how upsetting your situation is right now.

Selected Value: 0

What is your primary goal for coaching?

When did your concerns(s) begin?

Please describe any important events occurring at that time or since then which may have contributed to the problem(s).

Have you been in therapy?

Yes
No

If yes, please indicate when and how long were you in treatment and with whom.

Who are the people you turn to in times of need?

Please check all of the symptoms in the following list that you are currently experiencing:

PERSONAL INFORMATION

Self

Occupation:

Employer:

Education Level:

Religion: as child/adult

Military Service:

Yes
No

Name and age of: Father

Name and age of: Mother

Name and age of: Stepfather

Name and age of: Siblings*

Parent / Guardian

Occupation:

Employer:

Education Level:

Religion: as child/adult

Military Service:

Yes
No

Name and age of: Father

Name and age of: Mother

Name and age of: Stepfather

Name and age of: Siblings*

HEALTH HISTORY

Do you have any current health problems?

Yes
No

Name of Primary Physician:

Have you been on any medication during the past six months?

Yes
No

If yes, please describe:

Last appointment:

Medication/ Illness/ Dose / Date Began/ Ended

List all current non-prescription vitamins and or supplements:

Please indicate your level of use: Tabacco

Selected Value: 0

Please indicate your level of use: Alcohol

Selected Value: 0

Please indicate your level of use: Recreational Drugs

Selected Value: 0

Have you ever been hospitalized for major health, psychological, drug, or alcohol problems?

Yes
No

If yes, please describe:

Referral Source:

May we thank the person for the referral?

Yes
No

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.

Please Sign Your Name

Clear Signature

Date