Gestalt/IFS Coaching Intake Form

Gestalt/IFS Coaching Intake Form
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Marital Status
Email
example@example.com
Occupation
Cell Phone
Family Background
How is Your Relationship With Your Mother?

1

2

3

4

5

1 is Very Bad, 5 is Amazing
Comment (not required)
How is Your Relationship With Your Father?

1

2

3

4

5

1 is Very Bad, 5 is Amazing
Comment (not required)
# of Siblings
Any comment - significant history with any siblings? (not required)
Any significant family history you'd like to mention? (Family patterns, traumatic events, death etc?)
Medical History
Are you currently taking prescription medication?

YesNo
If Yes, please specify:
Any substance abuse or addictions you'd like to mention?
Any significant medical events you'd like to mention? (Illness, health concerns, etc.)
Mental Health History
What is your main reason for seeking help?
What is your desired outcome of us working together?
Have you seen a counselor, psychologist, psychiatrist or other mental health professional before?

YesNo
Any comment about that experience? (not required)
Do you have a meditation practice?
Life Balance

This is just to give an overview into the major areas of your life.
How is your Work life? (Job/Career/Purpose)

1

2

3

4

5

1 is Not Great, 5 is Great
How is your Family life? (Partnership, Friendships, Connection)

1

2

3

4

5

1 is Not Great, 5 is Great
How is your Financial life?

1

2

3

4

5

1 is Not Great, 5 is Great
How is your Health?

1

2

3

4

5

1 is Not Great, 5 is Great
How is your Play life? (Fun, Hobbies, Creativity)

1

2

3

4

5

1 is Not Great, 5 is Great
Any of these you'd like to elaborate on?
Any other comments/concerns?
*Your signature below indicates that the information you have provided above is truthful.
Date

MonthDayYear
Date
Signature

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Gestalt/IFS Coaching Intake Form

Family Background

Medical History

Mental Health History

Life Balance