Client Intake Form

Last Name:
First Name:
Middle:
Street:
City:
State/Province:
Country:
ZIP/Postal Code:
E-Mail Address:
Home Phone:
Cell Phone:
Skype ID:
FaceTime ID:
Is it OK to leave a message at all phone numbers and e-mail? If not, please specify.
How do you prefer to communicate for the coaching sessions? Phone, Facetime, Skype, doxy.me?
Do you have any history or current use of drugs and/or alcohol? If yes, describe:
Are you currently seeing a therapist? If yes, briefly describe reason for therapy.
Is there anything else you would like me to know about you or your circumstances before we begin?
By typing my name as a signature below I attest that I have read the New Coaching Client Welcome and Agreement, understand, and agree to everything contained therein.
By typing my name as a signature below I attest that I have read the Coaching Contract, understand, and agree to everything contained therein.