Client Intake Forms

Full Legal Name

Preferred Name

Email

Phone

Address

Date of Birth

Emergency Contact

Name

Relationship to You

Contact Number

Relationship Information

Reason for Seeking Coaching

Single choice

Option 1

Option 2

Primary Reason(s) — check all that apply:

Mental Health Information

Are you currently working with a mental health provider (therapist, counselor, psychologist, psychiatrist)?

Yes

No

If yes, provider name:

Safety Screening — Are you currently experiencing any of the following?

Single choice

Suicidal thoughts or thoughts of self-harm

Domestic violence or intimate partner violence

Substance abuse or addiction concerns

Severe mental health symptoms (hallucinations, psychosis, debilitating anxiety or depression)

If you checked "yes" to any item above, coaching may not be the appropriate service for your current needs. The coach will discuss referral options to a licensed mental health professional with you before beginning coaching services.

Additional Information

What are your goals for coaching? (Please share what you hope to achieve)

Is there anything else you’d like the coach to know?

Signature

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