Client Intake Form
Gwendolyn McLeod, M.S. C.A.M.S, C.D.V.S., C.P.C.
2303 US HWY 1 Suite 12 Ft. Pierce FL 34946 Phone:772-788-2113
Disclaimer
Please note that coaching is NOT a suitable replacement to treat mental illness. If you are seeking or considering working with a therapist, please consult a licensed mental health professional. Furthermore, Successful Solutions Coaches are Independent Contractors and are not practicing attorneys and do not provide legal advice or legal services. Successful Solutions Coaches, cannot, and does not guarantee any specific outcomes. Therefore, I cannot billed insurance companies and my services are self-paid by my clients.
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Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
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What type of service
Anger Management
Life Coaching
Business/Career Coaching
Premarital Coaching
Relationship Coaching
Parental Coaching
If this a court ordered service please provide case number and charges below:
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Have you in the past or currently under treatment for a mental health condition or ever been prescribed medication for treatment of a diagnosed mental health condition.
Please Select
Yes
No
Do you suspect or believe that you may be having symptoms of mental health that requires treatment by a psychiatrist or psychologist?
Please Select
Yes
No
Have you ever been or are you currently under treatment for any type of substance abuse?
Please Select
Yes
No
1. What influenced your decision to seek out assistance and support?
2. What would you like to get out of coming to these sessions?
3. What part of your life is working well? What part of your life could be working better?
4. What do you want to focus on in your work with me?
5. What do you think are your biggest personal strengths? Weaknesses are?
6. How would you describe your support system? Who are the people who believe in you? Unconditionally, challenge you or frustrate you? Please describe those people.
7. What qualities do you value most in other people?
8. What inner qualities would you like to have more of? (ie. joy, integrity,self-trust, self-love, confidence, etc)
Next Step
Thank you for completing the intake form, someone will contact you and schedule a consultation appointment.
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