NEW CLIENT INTAKE New Client Intake (23/9/2022) "*" indicates required fields Name* Gender Male Female Other Date of Birth: MM slash DD slash YYYY Age: Address: Street Address City ZIP / Postal Code MobileEmail* Marital Status: Married Divorced Single Separated Living w/partner Widow/er Name of Spouse or Partner: Emergency Contact: PhoneRelationship Referred by: Have you been in therapy before? Yes No When? Issue: Have you been in coaching before? Yes No When? Issue: Are you currently under the care of a physician? If so, for what: List all medications: (prescribed or over-the- counter):Alcohol or non-prescribed drugs: (amount and frequency):Have you ever been evaluated or treated for chemical dependency, depression, anxiety, eating disorders, or other behavioral or mental health issues? If so, please describe:What are your current goals for coaching?Anything else you’d like to share?Your signature below indicates that you give permission for your coach permission to use the Emergency Contact information in the case of an emergency during our coaching relationship.Client SignatureDate MM slash DD slash YYYY Name of your Coach Δ Make Appointment Marcy
