Coaching & Counsel Intake Form

Coaching & Counsel Intake Form

Helping People Heal & Soar Higher in Purpose
Patient Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Date of Birth

Month Day Year
Date
Email
example@example.com
Home Phone

Area Code Phone Number
Cell Phone

Area Code Phone Number
Preferred Method of Contact

E-mail Home Phone Cell Phone
Marital Status
Employment
Primary Care Provider
Referral Name

First Name Last Name
Emergency Contact Information
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Relationship
Insurance Information
Name of Insurer

First Name Last Name
Insurer Phone Number

Area Code Phone Number
Subscriber Name

First Name Last Name
Subscriber Date of Birth

Month Day Year
Date
Subscriber Relationship to Patient
Group Number
Policy Number
Medical History
Please check all the apply

None Allergies Anemia Angina Anxiety Arthritis Asthma Atrial Fibrillation Benign Prostatic Hypertrophy Blood Clots Cancer Cerebrovascular Accident Cronary Artery Disease COPD (Emphysema) Crohn's Disease Depression Diabetes Gallbladder Disease GERD (Reflux) Hepatitis C Hyperlipidemia Hypertension Irritable Bowel Disease Liver Disease Migraine Headaches Myocardial Infarction Osteoarthritis Osteoporosis Peptic Ulcer Disease Renal Disease Seizure Disorder Thyroid Disease Trauma
Do you use tobacco?

No Daily Weekly Less Former User
Do you use alcohol?

No Daily Weekly Less Former User
Caffeine use?

No Daily Weekly Less Former User
Have you been convicted of drug related charges?

Yes No
Please explain the circumstances
Are you currently taking prescription medication?

Yes No
Prescribing Doctor's Name

First Name Last Name
Prescribing Doctor's Phone

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

Yes No
Please specify:
Family history

Adopted Alcoholism Allergies Asthma ArthritisBlood Disease CAD (Heart Attack) Cancer CVA (Stroke) Depression Developmental Delay Diabetes Eczema Foster Care Hearing Deficiency Hyperlipidemia (High Cholesterol) Hypertension (High Blood Pressure) Irritable Bowel Disease Learning Disability Mental Illness Tuberculosis Obesity Osteoarthritis Osteoporosis PVD Renal Disease Residential School Trauma Bullying or Emotional Abuse
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?

Yes No
Counsellors Name

First Name Last 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

Month Day Year
Date
Signature

Clear
Should be Empty:

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Coaching & Counsel Intake Form

Emergency Contact Information

Insurance Information

Medical History

Coaching History