New Client Discovery Intake

New Client Discovery Intake
Self Discovery Questionnaire

This questionnaire is designed to identify important themes, treatment goals, and preferred strategies to support us in developing the most effective therapeutic/coaching relationship. Please fill out all areas to the best of your ability (and comfort level) before our first session together. Don't worry too much about it - we can always discuss anything that feels relevant during our sessions and the treatment trajectory and goals are always your choice and are modifiable at any point in time.
First things first. Tell me some of your demographic background and how you'd like me to refer to you!
Name

First NameLast Name
Legal Name (if different from above)

First NameLast Name
Pronouns
Please list all pronouns you identify with - feel free to leave blank if you prefer to only be referred to by name!
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
How May I Reach You At This Number?
E-mail
example@example.com
Cultural Considerations (anything that feels important for me to know about who you are, the sociocultural locations you inhabit, and what may be helpful for me to make your care as supportive as possible)
Consider areas such as: Race/Ethnicity, Gender Identity, Sexual Orientation, Disability or Chronic Illness, etc.
How Did You Discover My Services?
What Location Will We Be Meeting At?

Current Life Experience

This section is intended to provide you with a snapshot of your current life experience. We will refer to this assessment as we progress through our sessions to track changes and orient therapeutic interventions and goal-setting in a way that truly supports your needs. There will be several different sections that you'll progress through.
Well Being and Satisfaction Assessment

For each domain, consider your current level of satisfaction on a scale of -10 (completely dissatisfied) to 10 (completely satisfied). Slide the gray bar to the number which best reflects your predominant experience over the past couple of weeks.
Livelihood & Lifestyle
Finances / Money
Work / Career
Lifestyle (Travel, Time Freedom, Accommodations, etc)
Home Environment
Comments (optional)

Whew! You Did It!!!

Now that you're done... Go ahead and click the submit button! If you have any questions, please feel free to e-mail me at captionsoflife@gmail.com or text/call me at 216-678-3242 OR 951-374-9511. I look forward to seeing your answers and connecting with you soon!
Should be Empty:

	Strongly Averse	I am unsure/curious...	Haven't tried but would like to!	Have already tried and love it!
Somatic (Body Centered) Psychotherapy
Expressive Arts Therapy
Traditional Life Coaching
Client-Centered Counseling (Talk Therapy)
Dream Work
Authentic Movement
Desire Mapping
Parts Work (IFS)
Health & Wellness Coaching
Eating Disorder Intuitive Therapy
Energy Leadership Index (ELI) Assessment & Coaching
Dialectical Behavior Therapy (DBT)

Self Discovery Questionnaire