Client Intake Form

1
Your personal details* This field is required.
First Name
Last Name
Please enter your email
Your mobile number
Your date of birth
Please Select
Please Select
Yes, I am over 18 years old
No, I am under 18 years old
Please confirm are you over 18 years old
Please Select
Please Select
New Zealand
Australia
Singapore
Other
Country of Residence
2
Parent or Guardian Details and Declaration As a parent or guardian, I confirm that I am aware of and approve of the clients participation in the services provided by Redefined Coaching. I understand what the services include. I also understand that the information provided by the client in the form may be used in accordance with the company's privacy policy. I declare that I have the legal authority to give consent on behalf of the underage client and agree to be responsible for any actions or decisions made by the client during the course of their participation in the services. I acknowledge that I have read and understood the terms and conditions of the services, including any associated risks, and agree to be bound by them on behalf of the underage client.
Please Select
Please Select
Yes
No
I agree to the above declaration
First & Last Name
Please enter your email
Please enter your phone
Describe your relationship to the client (father/mother/parent/family-member/non-family member/carer)
3
Who are you currently working with
Registered Doctor
Psychologist
Therapist
Counselor
4
Registered DoctorPlease enter their details
Doctors Full Name
Doctors Name of Practise
Please enter your Doctors email
Please enter your Doctors phone number
5
PsychologistPlease enter their details
Psychologist Full Name
Psychologist Name of Practise
Please enter your Psychologist email
Please enter your Psychologist phone number
6
TherapistPlease enter their details
Therapist Full Name
Therapist Name of Practise
Please enter your Therapist email
Please enter your Therapist phone number
7
CounselorPlease enter their details
Counselor Full Name
Counselor Name of Practise
Please enter your Counselor email
Please enter your Counselor phone number
8
Release of information* This field is required.We understand the importance of providing you with the best possible care, and that's why we may share information about your treatment with certain healthcare practitioners who have been chosen to help us get a full picture of your situation. This helps us make sure that all medical practices are in line with your best interests. We'll be sharing updates from our weekly sessions with you, which will give a comprehensive overview of your progress. This information will be sent to your doctor, psychologist, therapist, or counselor who is currently helping you with your treatment. This sharing of information will continue until further notice. We believe that this information exchange is important for your continued well-being and successful treatment. Do you consent to the release of this information as described above?
YESNO
9
What is your storyPlease briefly share your story
Huge
Large
Normal
Small
Ok
Ok
10
What are your goals for coachingPlease briefly share what you expect to get out of coaching.
Huge
Large
Normal
Small
Ok
Ok
11
Terms and Conditions* This field is required.I agree to Redefined Coaching's Policies previously mention and Privacy Policy listed on our website.
YESNO
Should be Empty: