Coaching & Counsel Intake Form

Coaching & Counsel Intake Form

Helping People Heal & Soar Higher in Purpose
Patient Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Email
example@example.com
Home Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Preferred Method of Contact

E-mailHome PhoneCell Phone
Marital Status
Employment
Primary Care Provider
Referral Name

First NameLast Name
Emergency Contact Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Relationship
Insurance Information
Name of Insurer

First NameLast Name
Insurer Phone Number

Area CodePhone Number
Subscriber Name

First NameLast Name
Subscriber Date of Birth

MonthDayYear
Date
Subscriber Relationship to Patient
Group Number
Policy Number
Medical History
Please check all the apply

NoneAllergiesAnemiaAnginaAnxietyArthritisAsthmaAtrial FibrillationBenign ProstaticHypertrophyBlood ClotsCancerCerebrovascular AccidentCronary Artery DiseaseCOPD (Emphysema)Crohn's DiseaseDepressionDiabetesGallbladder DiseaseGERD (Reflux)Hepatitis CHyperlipidemiaHypertensionIrritable Bowel DiseaseLiver DiseaseMigraine HeadachesMyocardial InfarctionOsteoarthritisOsteoporosisPeptic Ulcer DiseaseRenal DiseaseSeizure DisorderThyroid DiseaseTraumaOther
Do you use tobacco?

NoDailyWeeklyLessFormer User
Do you use alcohol?

NoDailyWeeklyLessFormer User
Caffeine use?

NoDailyWeeklyLessFormer User
Have you been convicted of drug related charges?

YesNo
Please explain the circumstances
Are you currently taking prescription medication?

YesNo
Prescribing Doctor's Name

First NameLast Name
Prescribing Doctor's Phone

Area CodePhone Number
Have you had any surgeries in the past 5 years?

YesNo
Please specify:
Family history

AdoptedAlcoholismAllergiesAsthmaArthritisBlood DiseaseCAD (Heart Attack)CancerCVA (Stroke)DepressionDevelopmental DelayDiabetesEczemaFoster CareHearing DeficiencyHyperlipidemia (High Cholesterol)Hypertension (High Blood Pressure)Irritable Bowel DiseaseLearning DisabilityMental IllnessTuberculosisObesityOsteoarthritisOsteoporosisPVDRenal DiseaseResidential School TraumaBullying or Emotional AbuseOther
Coaching History
Why are you seeking coaching ?
What do you expect from this Coaching session
Have you seen a ,counselor, psychologist, psychiatrist or other mental health professional before?

YesNo
Counsellors Name

First NameLast Name
Reason for seeking help
Average hours of sleep per night
Please describe any other experiences you have had problems with
Additional comments or concerns
How do you see yourself
Do you have a dream and goals in life . Please Explain
What are your strengths of what you like to do
Out of a scale from 1 - 10 how positive are you
What is the MOST Important area you would like to work on today
CANCELLATION POLICY

If you fail to cancel a scheduled appointment with in 24 hrs client will be  billed for the entire cost of your missed appointment.

A full session fee is charged for missed appointments or cancellations with less than a 24-hour unless it is due to illness or an emergency.

PAYMENT FOR SERVICE

Is paid by e transfer to Healing 4 you (Treneta Bowden) at website email healingis4you@yahoo.com

CONSENT

I give full consent to receive stress coaching session and counsel on the date of :

I understand that all coaching & counsel sessions are held in confidentiality. I am committed and disciplined to do the homework required to achieve my healing and soar in my growth journey .
I blanks give full consent to receive coaching service on the date of _____________________ by Treneta Bowden .I understand that all coaching sessions are held in confidentiality and I am responsible for my personal growth . I am disciplined to do the homework required and the actions I need to achieve my goal . I am a winner and receive my healing and restore from pain and think forward to soar in my purpose.
*Your signature below indicates that the information you have provided above is truthful.
Date

MonthDayYear
Date
Signature

Clear
Should be Empty:

Coaching & Counsel Intake Form

Emergency Contact Information

Insurance Information

Medical History

Coaching History