New Client Information

I understand that life consulting is not designed to be a form or treatment for a mental health illness that impacts my ability to live life in a way that I or others find acceptable , Signature Below*

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Have you ever experienced a mental health challenge that has impacted your ability to live life in a way that feels acceptable to you or others (e.g., bipolar disorder, schizophrenia, PTSD, anxiety, or depression)?If yes, please describe how this has affected your daily life.- Write N/A if not applicable*
Have you ever been under the care of a mental health professional for this challenge (e.g., inpatient care, outpatient team, psychologist, psychiatrist)? If so, please describe the treatment you received.- Write N/A if not applicable*
Are you currently on any medication to help with a mental health difficulty? How long have you been taking this medication- Write N/A if not applicable?*
Please describe how you feel this medication affects you. If you are currently taking medication, please let us know if you plan to stop taking it during the course of our meetings together.- Write N/A if not applicable*
Have you ever engaged in any self harm behaviors (i.e. cutting, burning, biting, hitting, starvation, binging and purging)?If yes, how long did you engage in these behaviors and how frequent were they?- Write N/A if not applicable *

Have you ever experienced thoughts of wanting to end your life? If so, how long ago was this? How frequently would you experience these thoughts?- Write N/A if not applicable*
Have you ever attempted to take your own life?- Write N/A if not applicable*

yesno
How long ago was this? Was this an impulsive decision or something that was thought out?- Write N/A if not applicable*
Are you currently experiencing thoughts of wanting to end your life?- Write N/A if not applicable*
Emergency contact Information (someone who lives near you) - please include their name, relationship to you, and phone number:
Name*

First NameLast Name
Relationship to you?*
Phone Number*
Please enter a valid phone number.
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