Name * First Name Last Name Email Address * Cell (###) ### #### Other Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth MM DD YYYY Gender Female Male Other Marital Status Single Domestic Partner Married Separated Divorced Occupation Company Emergency Contact Name * First Name Last Name Emergency Contact Phone * (###) ### #### Emergency Contact Relationship to You * Name of Primary Care Doctor First Name Last Name Phone of Primary Care Doctor (###) ### #### Please Note Any Treatment You Are Currently Receiving from ANY Health Care Provider Reason(s) for Wanting a Coach/Primary Goal(s) Area(s) of Interest Career/Work Health/Wellness Wealth/Money People/Relationships Personal Growth Spirituality Other Check any Issues You Have Anger, Frustration, or Resentment Balancing Multiple Areas of Life Chronic or Current Pain Clutter, Procrastination, or Feeling Stuck Depression or Grief Fears or Phobias Lack of Confidence or Low Self-Esteem Past Trauma or Painful Memory Recurring Negative/Limiting Thoughts Relationship Challenges Sports Performance Issues Stress/Anxiety Wanting to Be More Effective at Work (or Home) Wanting to Experience More Joy and/or Peace of Mind Weight Issues Other Are any of these urgent or serious for you? * Have you seen a therapist for these or any other issues, and if so, when? What, if any, medications are you taking? Are you now, or have you ever been suicidal? If so, when and why? * Do you or anyone in your family have a history of substance abuse? If yes, please specify. Do you have any metal fillings or crowns? If so how many? Do you have any other metal plates, pins or appliances in your body? Anything else you'd like me to know? Thank you for your interest in working with me! I will be in touch shortly.
