Counseling & Coaching Intake Form

Please be as specific as possible and submit before the start of our initial session. If you have any questions or concerns you can email me or we can discuss during our session. I am so very grateful you are here! See you soon.

First Name

Last Name

How do you like to be addressed?

Address

Phone

Birthday

Month

Day

Year

Emergency Contact Name, Relationship, and Phone Number

Intimate Relationship Status

Employer/Position- Impact of career on stress levels (1-10)

Active/Former Military

Yes

Education

Current Medical Provider Name and Contact

Current Medications- Prescription, OTCs, Supplements (name and dosage)

Mental Health History (Previous/Current Diagnosis, Psychiatric care, etc.) Please Describe

History of Self/Harm, Suicidal Attempts or Ideations (Please describe in additional comments below if answering Yes)

Yes

Spirituality (Any spiritual/religious beliefs & practices)

Self-Care Activities (Hobbies, Interests, What do you do for fun, how do you care for yourself?)

Please list Primary Relationships that may come up in session and how long they have been a part of your life (i.e. Mom- Carol, Best Friend- Sarah 10 years)

Briefly explain your motivation for seeking support at this time. Is there a specific goal you want to focus on?

Briefly explain what you hope to gain from our work together and how will you know it is working, what would that look like for you?

Any additional comments or concerns?

Counseling & Coaching Intake Form Please be as specific as possible and submit before the start of our initial session. If you have any questions or concerns you can email me or we can discuss during our session. I am so very grateful you are here! See you soon.

Counseling & Coaching Intake Form

Please be as specific as possible and submit before the start of our initial session. If you have any questions or concerns you can email me or we can discuss during our session. I am so very grateful you are here! See you soon.