COACHING – BACKGROUND & HISTORY

Who is your provider?*
Today’s date
MM slash DD slash YYYY
Client Legal Name
First Middle Last
Client Preferred Name
First Middle Last
Date of Birth
Month
Day
Year
Street Address
Street Address Address Line 2 City State ZIP Code
Preferred Email Address*
Would you like to subscribe to our newsletter?*
- Yes, keep me up to date with latest news and updates.
Client's Preferred Phone
Phone Type
- Cell
- Home
- Work
Gender Identity
Sex Assigned at Birth
Occupation
Employer or School (if student)
Marital status
Spouse/Partner (if applicable) and Occupation
Other family members and ages
(please note whether living in or outside of the home)
How did you learn about this practice
FINANCIALLY RESPONSIBLE PARTY
An adult client or an adult guardian who has assumed the cost of treatment. Payment is expected at the time of service.
Name
First Last
Relationship
Address
Street Address Address Line 2 City State ZIP Code
Emergency Contact
Relationship
Phone
Presenting challenges to address in coaching: How do these impact the relationship? How do these impact you? Describe emotionally, cognitively, physically, sexually.
HISTORY OF DIFFICULTY AND PRECIPITATING FACTORS
Goals you want to accomplish through coaching
If none reported, check here
- None reported
PERTINENT BACKGROUND
(# of siblings, marriages/significant relationships, children, impacting events, e.g. moves, developmental changes, sexual/physical/emotional abuse, trauma, divorce.)
SOCIAL/SPIRITUAL/INTERPERSONAL SUPPORT SYSTEM OR ACTIVITIES
If none reported, check here
- None reported
Abuse &/or Neglect
- Yes
- No
If Yes to any of the above, please list contact person
What are your strengths, or other things you are particularly good at or enjoy doing?
Medical Information
Present health of client
Previous medication (not for common illnesses)
Current medications (include all and who is prescribing them)
Have you been hospitalized or had surgeries (please describe)
Any family history of mental health concerns?
(i.e. Adhd, learning disabilities, depression alcoholism, anxiety) or neurological disorders (i.e. seizures, Tourettes, autism)
Other care professionals you are currently undergoing treatment with including a therapist doing individual counseling or others (e.g. acupuncturist, chiropractor, medical specialists, etc.)
Physician
Phone
Address
Street Address Address Line 2 City State ZIP Code
Other
Phone
Address
Street Address Address Line 2 City State ZIP Code
Other
Phone
Address
Street Address Address Line 2 City State ZIP Code
Other
Phone
Address
Street Address Address Line 2 City State ZIP Code
Any other information that you feel is important for me to know?
Phone
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COACHING – BACKGROUND & HISTORY

FINANCIALLY RESPONSIBLE PARTY

Medical Information