NEW CLIENT INTAKE FORM
Full Name
*
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Place of Birth
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Marital status: how long married, spouse's name
If not married but in a relationship: how long and partner's name
Past marriages: when? how long? reason for dissolution
Children: How many, ages, sex
Education background: amount of schooling, degrees, licenses, areas of interest
Career: Present job, other previous work
Hobbies and interests:
FAMILY BACKGROUND
Are your parents still married? If so for how long?
If divorced, how old were you when it happened?
If parent or parents are deceased, when and what did they die of?
Were either parent married before or after their marriage to each other?
How many children did your parents have together? Did they have other children?
Names and ages of your siblings
How would you describe your parents relationship?
What kind of person is your Father? (or whatever male brought you up)?
What kind of person is your Mother? (or whatever female brought you up)
When growing up, how did you get along with your Father? With your Mother? With your stepparents?
How did you get along with your siblings when growing up?
Did you have a religious upbringing? What denomination and how observant were you?
How would you describe your spirituality today?
HEALTH
Have you had any major accidents? What kind and when?
Major Illnesses: Please describe.
Surgeries? When and what for?
Allergies?
Emotional problems?
Previous psychotherapy: for what problems? Type of therapy? How long?
Do you take any medications currently? If yes, please list.
Have you ever had any problems with drugs, alcohol, food, spending, sex, cigarettes, etc? If yes, please describe.
VERY EARLY HISTORY
What was your parents’ relationship like when you were conceived?
Were you wanted, planned, unplanned?
What was your Mom’s pregnancy like?
What were you told about your birth?
Any complications for Mom and baby?
Is there anything about your birth that is still an issue for you today?
OTHER
Are there any traumatic events that are still affecting your life today?
Is there anything else you want me to know about you?
What are the three most important goals that you have during our coaching?
Submit
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