Intake form

Full name (required)

Email address (required)

Phone number (required)

Street address

City

State / Province

Postal / Zip Code

Country

Date of birth

Marital Status and Occupation

Emergency Contact and Phone Number

Are you currently taking any medications? If so, please list all of them.

What are your current eating and sleeping habits? Do you consume caffeine? If so, how much?

Have you ever had therapy before?

What issues do you want to address? Please list each of them and describe them in detail.

What are the top 3 issues currently impacting your life?

What is your biggest challenge regarding the issue above?

When did the issue first present itself? What was going on in your life?

What are the symptoms, triggers, and habits surrounding your issue?

Please describe your childhood in as much detail as possible.

Please describe your relationship with your family.

What are your fears and frustrations? Please describe them below.

Do you have any traumas? Please describe them below.

On a scale of 1-10 how much do you want to overcome your issue, (1 is not motivated to achieve what you want to overcome, 10 is highly motivated.)

How do you show yourself self-love?

What outcomes are you expecting from the coaching session? What will your life look like without the issue?

What do you want to achieve in order to consider the sessions successful?

I confirm I understand Terms and conditions and privacy policy.