INITIAL CONSULTATION DISCOVERY FORM

INITIAL CONSULTATION DISCOVERY FORM

Confidentiality Notice: All information provided in this form is strictly confidential and protected under client-coach confidentiality. It will be used solely for the purpose of delivering appropriate coaching support. Please complete this form in full and schedule your appointment accordingly. Take your time to answer these questions honestly. There are no right or wrong answers.
Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Date of birth*

MonthDayYear
Date
Preferred Contact Method*

PhoneEmailText
Best time to call?*

Hour Minutes

AM/PM Option
Emergency Contact*

First NameLast Name
Relationship*
Phone Number*
Please enter a valid phone number.
How did you hear about Victim 2 Victor Coaching, LLC?*

WebsiteSocial MediaReferralOther
What do you hope to gain from this session?*
Relationship Status*

SingleMarriedSeparatedDivorcedIn a relationshipOther
Living Situation*

Own HomeRentWith Family/FriendsOther
Quick Safety Check*

I feel physically safe in my current situationI have immediate safety concernsI have a safe place to go if neededI need help with safety planning
Current Situation*

Currently in a relationship with a Narcissistic PersonRecently Left a relationshipCo-Parenting with a Narcissistic PersonDealing with a Narcissistic Family memberWorkplace Narcissistic AbuseOther
Duration of abuse?*

Less than a year1-5 years5-10 years10+ years
Do you have Children?*

ChildrenNo Children
Ages of Children*
Custody*

Sole CustodyShared CustodyOther Arrangement
What are your primary concerns?*

Emotional well-beingFinancial SecurityPersonal SafetyLegal guidanceChildren's well-beingSetting BoundariesBuilding ConfidenceOther
Do you have a support system, if so who?*

FriendsFamilyTherapistSupport GroupNone CurrentlyOther
What prompted you to seek help at this time?*
Briefly describe the challenges or concerns you are currently facing?*
Have you ever worked with a coach or therapist before?*

YesNo
When you express your feelings, needs, or concerns, how does your partner (or the person in question) typically respond?*
Do you feel like you have to walk on eggshells around this person to avoid conflict or upsetting them?*

Yes, oftenSometimesRarelyNo
If yes, can you describe a situation where you felt this way?*
Can you recall a time when they made you feel deeply loved, only to later criticize, devalue, or ignore you?*
Have you ever been blamed for things that were not your fault or made to feel guilty even when you did nothing wrong?*

Yes, all the timeSometimesRarelyNo
Can you give an example?*
Do you feel like this person isolates you from family, friends or other support systems?*

Yes, they discourage me from talking to othersYes, but they do it subtly (eg making me feel guilty for seeing or talking to loved ones)No, they encourage me to have relationships outside of them
If yes, how has this affected your life?*
When they hurt you emotionally (or physically), do they deny it, minimize it, or turn it around on you?*

Yes, they always deny doing anything wrongYes, but sometimes they apologizeNo, they take full responsibility for their actions
Can you recall a specific instance?*
Have you noticed extreme highs and lows in your relationship with this person? (eg times when they shower you with affection, followed by periods of coldness or cruelty?)*

Yes, this happens a lotSometimes, but not extremeNo, they are consistent in their behavior
Describe how this pattern makes you feel*
Do you feel emotionally, mentally, or even physically drained after interactions with them?*

Yes, I feel exhausted and confusedSometimes, but try to brush it offNo, I feel energized and supported
What do you notice in yourself after dealing with them?*
Have you ever doubted your own reality, memories, or felt like you were :going crazy" because of their words or actions?*

Yes, I often feel like I can't trust my own judgementSometimes, but I try to stay groundedNo, I feel confident in my perception of reality
If, yes, what kind of things do they say or do to make you feel this way?*
Does this person use alcohol or other substances? If so, how does their behavior change when they are under the influence?*

No, they do not use alcohol or substancesYes, occasionally, but their behavior stays the sameYes, frequently and their behavior changes drastically
If their behavior changes, describe how it affects you*
Are they physically abusive?*

YesNo
Physical Health Issues*

Sleep issuesHeadaches & MigrainesDigestive IssuesWeakened Immune systemWeight FluctuationsHigh Blood Pressure / Heart DiseaseMuscle Tension / Chronic painChronic Stress
Mental and Emotional health issues*

Anxiety and Panic DisordersDepressionPost Traumatic Stress Disorder (PTSD) & Complex PTSDLow Self Esteem & Identity ConfusionEmotional DysregulationSuicidal Thoughts or Self HarmCognitive DissonanceStockholm Syndrome or Trauma Bonding
Are there specific areas you would like to focus on? (Check all that apply)*

Recognizing the signs of narcissistic abuseHealing from emotional and psychologocal traumaRebuilding self esteem and confidence after abuseSetting and enforcing healthy boundariesBreaking Trauma bonds and detaching from the narcissistcoping with gaslighting and manipulationUnderstanding Narcissistic family dynamicsCo-parenting with a narcissisitRecovering from Financial AbuseOvercoming fear, guilt and self doubtOther
Do you have any concerns about the coaching process?*

YesNo
Are you currently experiencing any crises situations that require immediate attention?*

YesNo
Any additional information that should be taken into consideration?
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