Client Intake Form

Client Intake Form

For New Clients
Welcome! I can't wait to connect with you

The below series of questions are designed to paint the picture of who you are and who you hope to become through identifying your current obstacles and goals to work towards. Please fill out all areas to the best of your ability (and comfort level) prior to your complimentary 30-minute Discovery Call.
First things first. Tell me a little bit about yourself so that I have the necessary information, to not only reach you but to also understand what makes you... YOU!
Name

First NameLast Name
Preferred Name (if different than first name)
Nickname, shortened name, etc.
Pronouns
Please list all pronouns you identify with - feel free to leave blank if you prefer to only be referred to by name!
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
E-mail
example@example.com
Any other considerations to note? Whatever you feel is relevant that will help me understand the bigger picture of who you are, these details can often tell a richer story of your life experiences, beliefs & values.
Consider areas such as: Race/Ethnicity, Gender Identity, Sexual Orientation, Disability or Chronic Illness, etc.
How Did You Discover My Services?
I'm currently only offer sessions via Zoom, let me know if your preference is in person and I may be able to accommodate.

Thank-you for Reaching Out!

Thanks so much for taking the time to help me get a preliminary picture of who you are! I can't wait to connect and to get to know you better and to determine if my services are going to be of any help to you on your journey. Go ahead and click the Submit button, and If you have any questions, please feel free to e-mail me at info@jen-schmidt.com. I look forward to seeing your answers and connecting with you soon!
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Welcome! I can't wait to connect with you