Client Intake Form

Coaching Intake Form

Information gathering for coaching with Stuart. Please complete the following 12 questions to the best of your ability and comfort level before our first session together. However, this is not a requirement. All client personal information is kept safe and secure, and is highly confidential between the client and the coach. In accordance with any applicable UK laws and regulations. (GDPR).
Full Name*

First NameLast Name
Preferred Name ( If different )
Date of Birth*

MonthDayYear
Address*

Street Address

Street Address Line 2
CityCounty / State / ProvincePostcode / Zip Code
Contact Phone Number*

Area CodePhone Number
Contact Email Address*
example@example.com
Preferred Method of Contact / Time
Are you currently under the care of any other medical professional, healthcare provider, alternative medical or holistic practitioner or healer?*

YesNo
To allow me to support you fully, please tell me anything that you feel is important for me to know. Please remember it is not a requirement to fill out all of the following questions, or share anything that you feel uncomfortable with.
Have you worked with a coach, therapist, or other healing professional before? If yes, what was your experience like?
What would you like to achieve through this coaching?
How does stress or emotional overwhelm typically show up for you? (e.g., anxiety, numbness, avoidance, anger, physical symptoms).
What are your current coping mechanisms (healthy or unhealthy)?
Do you feel safe in your current environment?
Briefly describe your physical health and self-care including exercise and nutrition, hobbies and interests.
Do you experience any of the following regularly? (Tick all that apply)

Chronic tension or painSleep disturbancesDigestive issuesFeeling disconnected or DissociatedHyper vigilance ( feeling on edge, often )Difficulty setting boundariesOther
If other, please list them below.
Are there any topics or approaches you would prefer to avoid?
Is there anything else that you would like to add?
Well Done

Thank you for completing this questionaire, I appreciate that some of them would have been hard to answer.

If you have any questions please feel free to email me: info@freeoftrauma.com

I look forward to working and meeting with you soon.

Please click the submit button.
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Coaching Intake Form