Client Intakes for

#	EDIT	Intake Date	Updated On	General Information
#	EDIT	Intake Date	Updated On	General Information

Client Intake

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Client ID(Required)

Client Name(Required)

First Last

Family Information

Please provide a few simple pieces of information about your birth family.

Relationship Status

What is the status of your primary partnership relationship?

Partner Name

What is your partner's name?

First

Partner Information

What is your partner's name, DOB and origin.

Father Information

What is your father's name, when was he born, is he still alive?

Mother Information

What is your mothers' name, when was she born, is she still alive?

Sibling Information

Please describe each of your siblings in their birth order and include yourself in the list. Include their names, DOB, education and anything else that could help me understand hour relationship with them.

General Information

Do you have a personal mission or sense of purpose?

Having a personal mission or sense of purpose means that you have a clear moral compass and are high on Maslow's hierarchy of needs.

YES

UNSURE

Personal Mission or Vision

Please describe your vision or mission as best you can.

Considerations

Everybody is different, and I want to be respectful of any conditions you are aware of that could impact how I coach you. I will want to have a conversation with you about any conditions you list below.

Are you currently receiving coaching / therapy?

Are you neurodiverse? (i.e. on autism spectrum)

Do you have chronic depression?

Are you aware or dealing with of any attachment issues?

Other issue we sholld discuss

Please Describe

Please provide any additional information about the topics in the previous question.

Lichert Questions

My life is working very well

I can express my feelings clearly and easily

I know how to set effective personal boundaries

I am comfortable becoming appropriately vulnerable

I believe I am fine, just the way I am now

Blaming others is easier than taking responsibility

I believe I am not lovable/

I am good enough

I treat myself with compassion

I know what I want my life to look like

I am not good enough

I am not worthy

I am not lovable

I need to be prefect

It is OK to make mistakes

I have close friends I can trust and be honest with

I feel lonely much of the time

I don't really trust anybody

I belong to one or more supportive communities

I madidate on a regular basis

I am frequently depressed

I use recreational drugs too heavily

I have a connection with something greater than myself

My life is well balanced

I drink alcohol too much

Name

This field is for validation purposes and should be left unchanged.

Client Intake for

Client Intake

Family Information

Lichert Questions