FOLLOW-UP SESSION INTAKE FORM

FOLLOW-UP SESSION INTAKE FORM
Choose Package*

Single Power Session $150Breakthrough Package $397 (3-60 minute sessions sessions, over 3 weeks, consecutive)Monthly Maintenance $125/moQuarterly Victory Package $450 /$150/mo for 3 months(3-60 minute session over 3 months)
Date*

MonthDayYear
Date
Name*

First NameLast Name
Since our last session, I have (check all that apply):*

Implemented suggested strategiesMaintained BoundariesUsed coping techniquesFaced New ChallengesHad Breakthrough momentsExperienced setbacks
Rate your progress in these areas (1-5, 5 being best): Emotional well-being *

1

2

3

4

5

1 is Worst, 5 is Best
Rate your progress in these areas (1-5, 5 being best): Boundary Maintenance*

1

2

3

4

5

1 is Worst, 5 is Best
Rate your progress in these areas (1-5, 5 being best): Self-care practice*

1

2

3

4

5

1 is Worst, 5 is Best
Rate your progress in these areas (1-5, 5 being best): Financial independence*

1

2

3

4

5

1 is Worst, 5 is Best
Rate your progress in these areas (1-5, 5 being best): Support system strength*

1

2

3

4

5

1 is Worst, 5 is Best
Current Situation
Most significant changes since last session:*
New challenges that have emerged:*
Current primary concerns (check all that apply):*

Emotional HealingFinancial MattersRelationship BoundariesSelf WorthCareer/ProfessionalLegal IssuesFamily DynamicsOther
Session Focus
Main topics you want to address today:*
Tools/strategies that have been: Most helpful*
Least helpful*
Support Needs
Additional resources needed:*

Boundary setting toolsFinancial planning guidanceself-care strategiesCommunication scriptsLegal resourcesOther
Emergency situations since last session:*

No emergenciesYes
Please describe*
Goals
Short term goals for the next 2 weeks:*
Areas needing immediate attention*
Success celebrations (achievements since last session):*
Preparation
Questions for todays session*
Support needed from coach:*

AccountabilityStrategy RefinementResource referralsCrises planningOther
Make sure all questions are completed before submitting
Single Power FU Session*
breakthrough Followup *
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Session Date/Time
Coach Name

First NameLast Name
Session #:
Action Items
Followup Needed
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FOLLOW-UP SESSION INTAKE FORM

Current Situation

Session Focus

Support Needs

Goals

Preparation

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