Discovery Call Intake Form
Therapeutic Coaching
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Date of birth
-
Month
-
Day
Year
Phone Number + Country Code
+Country Code if outside of the USA
Emergency contact name and relation
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Emergency Contact Phone Number
Do you CURRENTLY or have in the PAST experienced any of the following:
Excessive alcohol use
Currently
Past
Never
Trauma
Currently
Past
Never
Panic attacks
Currently
Past
Never
OCD
Currently
Past
Never
Low confidence/low self-esteem/insecurity
Currently
Past
Never
Self-harm
Currently
Past
Never
Anger
Currently
Past
Never
Grief
Currently
Past
Never
Difficulty with concentration or confusion
Currently
Past
Never
Physical chronic pain (pain lasting more than 6 months unrelated to injury)
Currently
Past
Never
Irritable Bowel Syndrome (IBS)
Currently
Past
Never
Gender issues
Currently
Past
Never
Performance issues
Currently
Past
Never
Relationship issues
Currently
Past
Never
Substance abuse issues (non-alcohol)
Currently
Past
Never
Anxiety, excessive worry, fear
Currently
Past
Never
Phobia
Currently
Past
Never
Unwanted habits
Currently
Past
Never
Low mood / depression
Currently
Past
Never
Suicidal thoughts
Currently
Past
Never
Guilt
Currently
Past
Never
Insomnia or sleep issues
Currently
Past
Never
Exhaustion or chronic fatigue
Currently
Past
Never
Long term physical illness
Currently
Past
Never
Eating issues
Currently
Past
Never
Sexual issues
Currently
Past
Never
Spiritual issues
Currently
Past
Never
Abuse
Currently
Past
Never
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Any other problems not listed above?
Have you discussed the symptoms on this for with your doctor?
Yes
No
Are you taking anti-depressants?
Yes
No
Are you taking tranquilizers?
Yes
No
Are you taking sleeping pills?
Yes, every night.
No, never.
Sometimes.
Have you ever received any other form of psychiatric or psychological treatment?
Yes, I currently have a therapist.
Yes, I had a therapist in the past.
No, never.
Do you suffer or have you ever suffered from epilepsy?
Yes, and it is currently managed with medication.
No, I have never had epilepsy.
I outgrew epilepsy.
Are you prescribed any other psychoactive medication?
Yes
No
Do you suffer from asthma?
Yes, and it is controlled with medication.
No, I never had asthma.
I outgrew asthma.
Do you suffer from Diabetes?
Yes, I have Type 2, controlled through medication.
Yes, I have Type 2, controlled through diet and exercise.
Yes, I have Type 1, controlled through medication.
No, I do not have diabetes.
Please describe your family history situation briefly and your experience growing up.
What were the key events for you during your childhood, teens and formative years?
What have been the most stressful periods of your life to date? How do you feel they have impacted you?
Have you ever experienced any physical traumas such as an accident requiring medical attention or an operation?
Please list any other significant events you feel are relevant to our work together.
Submit
I verify that I have answered the questions on this intake form completely and truthfully to the best of my knowledge.
Today's date
-
Month
-
Day
Year
Date
Should be Empty: