Client Intake Form Please enable JavaScript in your browser to complete this form.Name *FirstLastDate of Birth *Email *Home PhoneCell Phone *Street Address *City, State, Zip *Describe your reason or recent events that have encouraged you to seek life coaching. *What are you wanting most in life right now? *Who are you when you're at your best? *What do you hope to accomplish with life coaching? *What other complementary therapies have you tried in the past? When? What did you find to be beneficial? *What is your profession? *How many hours per week do you work? *What is the level of stress in your job (scale of 1 to 10; 1 being the lowest, 10 being the highest)? *How long have you worked in your current job or owned your business? *What is your level of stress in your life in general right now (scale of 1 to 10; 1 being the lowest, 10 being the highest)? *What methods do you employ to help manage the stress in your life right now? *What methods have you employed to help manage stress in the past? *Please list any physical or mental health issues in the past 10 years. *Please list any physical or mental health issues 10 years or longer. *Please list your health care providers (primary care, mental health, and alternative providers) and if you are regularly seeing a health care provider for any particular concerns. *List current medications/herbs you are taking and for what reasons: *Briefly describe your diet or eating habits: *How many glasses of water do you drink per day? *How many caffeinated beverages do you drink per day? *How many alcoholic beverages do you drink per day/week? *Please describe your sleeping patterns: *If you have children, please list their names and ages.Emergency contact name, phone, and relationship to you. *Please describe any other concerns you would like to bring to my attention.Submit