New Client Intake

New Client Intake

Raina Garner Coaching & Counseling
Today's Date:*

MonthDayYear
Full Name:*
Name you would like to be called:
Gender pronouns:*

she/her/hersthey/them/theirshe/him/his
Birthday:*

MonthDayYear
Date
Cell Phone:*
Email:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Referred By (Refer someone who signs up and get 3 complementary coaching sessions!)*
Marital Status: *

SinglePartneredMarriedDivorcedWidowedPolyamorous
Occupation & Name of Employer:*
Emergency Contact's Full Name:*
Emergency Contact's Phone Number*

Area CodePhone Number
Name of Spouse/Partner(s) (if applicable):
Spouse/Partner Cell Phone:*
Name and Ages of Children (if applicable):

Coaching Questionnaire

Raina Garner Coaching & Counseling
Congratulations on taking a very important step in your life!

This questionnaire contains some powerful questions for you to consider before your first coaching session. This tool is meant to empower you to think clearly, become intentional and allow yourself the privilege to look for the answers. Think about what you want, what limitations you’re currently living with, and how you can move forward into the life you desire living.

To make the most of this session, I invite you to find 45 min to 1 hour where you can have an appointment with yourself, uninterrupted. Find an environment that is relaxing, pleasing, allows you to be at your best, and 100% focused on yourself. Give yourself the gift of time. Allow your answers to come from your whole engaged being.

I hope that you will make a choice to be open to all possibilities.
Are you sitting in a distraction free area where you feel relaxed and have blocked adequate time for yourself, allowing you to be at your best and 100% focused on yourself?*

Yes! (Awesome! Please continue...)No (Please come back to this form when you can answer yes. Thank you.

Your History
Remember everything here is completely confidential. The more you share here, the more I can support you and the better results you'll have.

What follows is a timeline of the events in your life that were less than supportive or caused stress for you. Please include all physical, emotional, sexual, mental, and other trauma. Please include divorces (yours and/or your parents), accidents, great transitions, events/memories, and anything that has impacted you in a less than supportive way. This is a walk down memory lane. Take your time and be as honest as you possibly can.

Write everything in the age range provided below. Email me right away if you have any questions (connect@rainagarner.com).
Ages 1-5*
Ages 5-10*
Ages 10-15*
Ages 15-20*
Ages 20-30*
Anything else you'd like to add?*

POLICIES:
- Communication - email is best connect@rainagarner.com. I’m an open door. We don’t work on the weekends so anything sent over the weekend will be answered on the next business day. You may also text me at 619-757-3790.
- We have a 48 hr cancellation policy. Appointments canceled or rescheduled within those 48 hrs are counted as an appointment used.
- No-call no-shows are a $50 charge and your session will be marked as used. If you are more than 10 minutes late for a session this will count as a no-show. You must notify your coach if you will be more than 5 minutes late. Your coach will do the same.
- All appointments are pre-booked to ensure weekly availability. You may reschedule any appointment, outside of the 48 hr cancellation policy, as you wish by going to your online hub.
Yes, I have fully read, understand, and agree to the terms above.
Should be Empty:

Coaching Questionnaire