CLIENT INTAKE WORKSHEET

Name ___________________________________    Date _________________

Phone ________________________________

Occupation ________________________   Education ___________________

Marital Status _______ Children ____________________________________

Members of your current household (their relation to you)

_______________________________________________________________

Hobbies _________________________________________________________________________________________________

MEDICAL HISTORY

Have you been under treatment (physical or psychological) in the past year? ______

Have you ever been treated for an emotional problem?  _______

Are you currently receiving treatment or counseling? _________

Are you presently taking any medication? ______________

Any suicidal thoughts, feelings or actions? _____________

Any homicidal or assaultive thoughts or feelings or anger control problems? ________

Any problems with (underline all that apply): eating, sleeping, chronic pain, heart, diabetes, epilepsy, recent weight changes, fears/phobias?

 COACHING AGENDA

 What are the 5 most important things in your life?

__________________________________________________________________________________________________________

What would you like to explore in coaching? 

_________________________________________________________________________________________________________

What are some changes you’d like to make in your life, if you had the support to do it well?

__________________________________________________________________________________________________________

What would you like to achieve in your life and career over the next three months?

__________________________________________________________________________________________________________

Client Signature

_____________________________________

Client acknowledges that he/she understands this questionnaire and that all information provided is complete and accurate to the best of his/her knowledge.