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Date

Month

Day

Year

First name

Last name

Middle Initial

Birth Date

Age

Gender *

Male

Female

Other

Street and Number

City

State

Zip

Country Code

Phone

Email

If referred by someone may I send him/her a thank you note?

If you have benefited from our work together, would you email me a short testimonial?

Yes

No

I mainly consider myself as religious, pragmatic/evidence based, spiritual/belief-based, belief-based but not spiritual, or other. Please explain.

What are the biggest changes you want to make in your life/relationship in the next 3 months?

What are the biggest changes you want to make in your life over the next 3 years?

What do you most want to achieve for yourself in your life/career/relationship?

What are the restraining forces keeping you from achieving these?

What do you expect to achieve as a result of hiring me?

What is the hardest thing in your life that you have had to overcome?

What major transitions or life changes have you had in the past two years? (Example: Entering or approaching a different age, a new or different relationship, job role, residence, a change in children’s ages/stages, etc.)

Who are or have been your major role models? Why?

Have you worked with a counselor/coach before or a similar one-on-one adult relationship? If so, what worked well for you and what did not work in the relationship(s)?

Who will be supporting you through this process?

History: What would you like to share with me?

On a scale of 1 to 10, 10 high, rate the amount of stress in your life right now.

CURRENT HABITS: Please describe your current habits in each of the following areas:

Smoking

Drinking

Drug Use

TV Use

Internet Use

Video Game Use

Caffeine Intake

Exercise

Eating

Sleeping

Fun & Relaxation

Chores & Responsibilities

Please list any psychiatric or “mental health” problems you have been diagnosed with:

Please list any medical or “physical” problems that you have been diagnosed with:

Please list any medications you currently take, and what they are taken for:

Name of Family Doctor:

I have read and agree to the Disclosure Statement

I have read and agree to the Terms and Conditions

Your Signature

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