Client intake form Please fill out some information and we will be in touch shortly. Thank you-Tony Name * First Name Last Name Date * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * Country (###) ### #### Birthday * MM DD YYYY Occupation * Marital Status * Children * (age/birthday/gender) Siblings * (age / gender) Members of your current household * (their relation to you, age & occupation) Religious/Spiritual beliefs Hobbies * Medical History Have you been under treatment (physical or psychological) in the past year?Have you been under treatment (physical or psychological) in the past year? (If so, describe) Name of physician or psychologist Phone # of physician or psychologist Phone# (###) ### #### Are you currently receiving treatment or counseling? Yes No Are you presently taking any medication? Yes No Have you had any prolonged illness? Yes No Any suicidal thoughts, feelings or actions? Yes No Any homicidal or assaultive thoughts or feelings or anger control problems? Yes No Any problems with (select all that apply): eating sleeping chronic pain heart diabetes epilepsy recent weight changes fears/ phobias Coaching Agenda How did you hear about my coaching services? * Reason(s) you desire coaching * Have you ever been coached in the past? * (If so, when & by whom, and what is the reason you are choosing another coach now?) If you could snap your fingers and make it so, how would your life and/or career look like? * What are the 5 most important things in your life? * What is exciting to you about coaching? * How would you prefer to be coached? * (your learning style/personality) Client E-Signature * Client acknowledges that they understands this questionnaire and that all information provided is complete and accurate to the best of their knowledge. Thank you!
