Form: New Client Background

The following questions help to determine whether my skill & qualifications are well matched to your circumstances.

Answering yes to any of these questions guides me in how I should conduct or adjust your coaching sessions.

If you answer yes, please briefly explain in the text space below the question.

Form: New Client Background Form

The following questions help to determine whether my skill & qualifications are well matched to your circumstances. Answering yes to any of these questions guides me in how I should conduct or adjust your coaching sessions. If you answer yes, please briefly explain.

Today's date:

YYYY

Name

First Name

Last Name

Best Contact Phone:

(###)

###

####

Email Address

Have you seen or are you currently seeing a medical doctor or qualified mental health professional for any of the problems you wish to address?

Have you ever been diagnosed with a psychological or mental health condition?

Are you currently on medication for a physical or mental health / psychological condition?

Have you ever considered or attempted suicide or homicide?

Have you had consistent success with employment, family and other relationships, or have any of those been a challenge for you?

Have you ever been convicted of a crime or spent any time in jail or prison?

Have you ever seen or hear things that other people don’t see or hear?

Do you &/or any of your family members drink alcohol or use recreational drugs? If so, do you feel it has created any problems for you?

Are you aware of any significant emotional trauma in your past, like physical, verbal or emotional abuse, losing your parents as a child, foster homes, sexual trauma, witnessing death, or anything of similar magnitude?

Transformational Coaching & Programs

Form: New Client Background

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