Discovery Call Intake Form

Discovery Call Intake Form

Therapeutic Coaching
Thank you for scheduling a Therapeutic Coaching Discovery Call. Please take some time to fill out the intake form in advance of our call.
Therapeutic Coaching brings a coaching approach to therapeutic processes. Certified Therapeutic Coaches are not licenced psychologist or psychiatrist and cannot diagnose conditions or prescribe medications. The Therapeutic Coaching model helps clients more clearly understand their strengths and resources while teaching tools of resilence and buidling the client's capacity and window of tolerence. Therapeutic Coaching can be used in support of licensed therapy work or as stand alone coaching work.
General Information
Full Name

First and Middle NameLast Name
Preferred Name
Preferred Pronouns
Physical Address
Email
example@example.com
Date of birth

MonthDayYear
Phone Number
Please include +Country Code
Emergency Contact Name and Relation
Name and Relation
Emergency Contact Phone Number
Please include +Country Code

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.
I verify that I have answered the questions on this intake form completely and truthfully to the best of my knowledge.
Today's date

MonthDayYear
Date
Should be Empty:

General Information