Client Information Form/Service Agreement Terms & Conditions

Client Information Form/Service Agreement Terms & Conditions

Please complete the form below. All information is kept confidential.
Client Information Form
Name

First NameLast Name
Date of birth

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Primary Phone

Area CodePhone Number
Alternative/Cell Phone

Area CodePhone Number
Type of Session Scheduled
Phone sessions/packages-Please indicate the phone number you would like called for your session(s)

Area CodePhone Number
E-mail
How did you learn about me?
Occupation
I identify myself as
Marital Status
Reason you are seeking services
Any previous efforts to resolve the issue?
Results:
What do you hope to achieve by receiving coaching?
Please check those events that you have experienced in the past 12 months
Have you ever been treated for emotional issues?
If yes, please explain
Any other health concerns I should be aware of?
Please list medications/ medicinal herbs for each
Do you currently have mindfulness and/or spiritual practices you use on a regular basis?
If yes, what practices do you use and how often do you use them?
On a scale of 1 to 10, please rate:
Quality of life
1=poor, 10=excellent
Health
1=poor, 10=excellent
Stress
1=No stress, 10=High stress
Quality of Sleep
1=poor, 10=excellent
Anxiety
1=No anxiety, 10=High anxiety
Focus
1=Poor focus, 10=Excellent focus
Happiness
1=Little happiness, 10=A lot of happiness
Peace of mind
1=Little peace, 10=A lot of peace
Irritability
1=No irritability, 10=A lot of ittitability
Service Agreement Terms & Conditions
Service Agreement Terms & Conditions: Joy Carter & JoyCarter.net
Click here to read service agreement terms and conditions.
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