New Client Intake Form
Contact Information
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
Location
Occupation
Gender
Female
Male
Other
Which one do you prefer to be contacted?
Email
Phone
Other
What is your goal/focus?
Why is this goal important to you?
What are your challenges stopping you from achieving this goal?
How specifically does this affect you?
How long has this been a problem for you?
Was there ever a time that this wasn't a problem for you?
Tell me about your childhood in relationship to this problem.
Tell me about your father, mother and siblings in relationship to this problem.
Tell me about events since the first event through your life in relationship to this problem.
What’s the relationship between all of these events and your current situation in life? (How does this affect you now?)
What possible benefits are there to having this problem? If there were a benefit, what would it be? ie; By having this problem it gives you an excuse not to put yourself out there, etc.
What have you been unwilling to do that has caused you to keep this problem? (Not taking certain actions- ie; not willing to exercise, eating poorly instead of eating healthy food, not prioritising time.
What are you willing to do in order to change this problem now?
What will you be thinking or knowing differently after we have finished our work together in order to know that the problem has disappeared?
How will you know that you have got what you came for?
Any further information about your situation or what you are wanting to achieve?
Any health conditions that you currently suffer from?
Why is it that you want to work with me?
What will you be thinking or knowing differently after we have finished our work together in order to know that the problem has disappeared?
How did you hear about me?
Date
-
Month
-
Day
Year
Date
Signature
Submit
Submit
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