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:
FAX:
Emergency Contact:
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?
Preferred coaching schedule Day(s) and Time(s):
In what time zone are you located?
Names and Ages of children:

Health Status
Description or diagnosis of pain:
Pain range: Your lowest to highest pain rating (0-10)?
When were you diagnosed?
What treatments are you currently receiving?
Surgical History related to your current pain?
Current Medications and doses for pain, sleep or mood:
What treatments do you find helpful?
What treatments were not helpful?
Do you have any difficulty with sleep?
Do you struggle with depression?
Do you suffer from anxiety?
Are you currently having, or recently experienced any suicidal thoughts?
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.