Client Intake Form

Attestation to Reading and Signing the 'Confidentiality and Liability Agreement'
Before continuing, you must read and sign the 'Confidentiality and Liability agreement' located on the 'Clients' page on the company's website and at this link: https://form.jotform.com/211375413693052. Queer Spectrum Life Coaching, LLC follows HIPAA (Health Insurance Portability and Accountability Act) and will keep all the information provided in this document safe under HIPAA guidelines. Do you attest that you have read and agreed to the company's 'Confidentiality and Liability Agreement?' *

Yes

Emergency Contacts
Contact Name and Relation *

Full Name (First and Last) Relation to Client
Contact's Phone Number
Not required if outside of USA. Please enter a valid phone number.
Contact's Email *
example@example.com
Add additional Emergency Contacts as you see fit.

General Health Information
Queer Spectrum Life Coaching, LLC, asks for the following health information to ensure that you responsible for your medical and health needs. By answering these questions you are affirming that you are not seeking life coaching for medical or theraputic services and you have those services and resources in place elsewhere. Queer Spectrum Life Coaching, LLC, is HIPAA compliant.
Do you have a primary medical provider/physician? *

Yes No Prefer Not to Answer
Are you routinely seeing other medical specialists (ex. counselor, psychiatrist, endocrinologist, rehab therapist, dermatologist, rheumatologist, etc.) for your more specific medical and health needs? *

Yes No I have no health needs that require services beyond what my primary medical provider/physician provides. Prefer Not to Answer
I understand that I am seeing Natalie from Queer Spectrum Life Coaching, LLC for coaching, and she does not provide me nor does she replace therapy or medical services, whether that be psychological, occupational, rehab or otherwise. I am responsible for my health and medical choices. *

Yes
Is there anything related to your health overall that you would like Natalie to know as your coach?

Coaching Questions
I am asking the following questions in order to better get to know you so we can get started sooner in our relationship rather than later. The more I know about your life, wants, needs, roles, and personality, the better I can help find ways to support you effectivly. Answers to these questions can be as sparse or detailed as you would like. Share what you find necessary and what you are comfortable with sharing. You may skip questions that don't feel applicable or that you are uncomfortable answering at this time.
What would you like to gain from my services? Alternatively, why are you seeking life coaching?
Do you have any particular goals, plans, or dreams you are working towards? Alternatively, what are you seeking to get/achieve/become or be in your life?
What are some of your strengths? What do you like about yourself?
What do you find rewarding? What brings you joy?
What are and how do you feel about your current eating, sleeping, and exercising habits?
How do you feel about daily routines and habits? Do you have or keep any daily routines? Do you try to keep one but aren’t keeping up with it as well as you would like?
What is your current living situation? House, apartment, etc.? With parents, siblings, roommates, significant others(s), with pets, by yourself? What do you like and dislike about where you live and your living situation?
Briefly, describe your day to day life. What are your responsibilities? What do you want and what do you need to do daily? Who or what do you see and do?
Do you consider yourself neurodivergent? If so, what does being neurodivergent mean to you?
Do you consider yourself queer? If so, what does being queer mean to you?
Do you consider yourself disabled and/or invisibly ill? If so, what does it mean to you?
Anything else you would like me to know as your coach?
This document has been filled out by the client and has been answered honestly and to the best of the client's ability. The client is legally responsible for themselves and has no legal guardian. The client understands the terms and conditions of the document. *

Yes
Signature *

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Client Intake Form

General Intake Information

Attestation to Reading and Signing the 'Confidentiality and Liability Agreement'

Emergency Contacts

General Health Information

Coaching Questions