Client Information & Intake Form

  • This is a confidential questionnaire that will provide me with information that will be helpful in coaching or therapy. If there are questions that you would rather not answer, leave them blank. You will receive an email copy of your form upon completion that you can print out for yourself.
  • You can draw the family tree on a sheet of paper and bring with you to the next session if you prefer.
  • Relationship History (choose the most important relationships):
  • Trauma History:
  • Current Marriage/Relationship:
  • In Your Marriage/Relationship, What Is:
  • Select a number from 1 to 5 where 1 is low and 5 is high.
    Please enter a value between 1 and 5.
  • Select a number from 1 to 5 where 1 is low and 5 is high.
    Please enter a value between 1 and 5.
  • Select a number from 1 to 5 where 1 is low and 5 is high.
    Please enter a value between 1 and 5.
  • Select a number from 1 to 5 where 1 is low and 5 is high.
    Please enter a value between 1 and 5.
  • Names, dates, type of therapy/coaching. Was it positive/negative/neutral?
  • This field is for validation purposes and should be left unchanged.