Hi client,
Would you please complete the following form to help us prepare for your initial session?
Thank you,
D E
ABOUT YOU
PRIMARY CONCERNS
Why are your interested in coaching? Briefly list current issues, struggles, and other difficulties you may be experiencing which you'd like to address in your session(s).
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PAST / CURRENT TREATMENTS
What methods of treatment have you engaged in? (coaching, counseling, psychiatry, physical therapy, functional medicine, supplements, natural therapies, etc.). Which of these are you still using?
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COACHING GOALS
TOP COACHING GOALS
What are your top 3 goals for coaching?
(e.g. anxiety management, life skills, medication tapering & withdrawal, medication symptoms management, etc.)
{"type":"textarea","name":"Goals_Top3","width":100,"value":"","size":"Small","validation":"NE","validationMessage":"Please complete this section.","height":80,"placeholder":"List top 3 goals..."}
OTHER GOALS
Are there any other issues that you would like to address during our sessions?
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MEDICATIONS
Have you ever taken any psychiatric medications? {"type":"radio","name":"Medication_YesNo","width":100,"value":"","size":"Small","validation":"C1","validationMessage":"Please select Yes or No here.","options":"Yes\nNo"}
If you answered "no," please skip ahead to "Other Prescription Medications."
CURRENT PSYCHIATRIC MEDICATIONS
What types of psychiatric medication are you currently taking (if any)?
Select all that apply:
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Please elaborate on the above medications, or add any that were not listed. Make sure to state your dosage (current and highest dose), how long you've been taking the medication, and your current status for that medication (full dose, tapering, other).
{"type":"textarea","name":"Medication_Psych_Current_Details","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":"List details here..."}
PAST PSYCHIATRIC MEDICATIONS
What types of psychiatric medication have you taken in the past (if any)?
Select all that apply:
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Please elaborate on the above medications, or add any that were not listed. Make sure to state your dosage (starting and highest dose), how long you took the medication, how you discontinued the medication (cold turkey, abruptly, slow taper, etc.), and how long it's been since your last dose.
{"type":"textarea","name":"Medication_Psych_Past_Details","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":"List details here..."}
OTHER PRESCRIPTION MEDICATIONS
Please list any other prescription medications you are currently taking.
{"type":"textarea","name":"Medication_Other","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":"List other non-psychiatric mediations here..."}
OTC MEDICATIONS / SUPPLEMENTSPlease list any over-the-counter medications or supplements that you are currently taking. (This may include vitamins, minerals, herbal products, CBD, THC, medicinal mushrooms, amino acids, or other non-prescription items.)
{"type":"textarea","name":"Medication_OTC","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":"List OTC medications and supplements here..."}
SUPPORT SYSTEM
CURRENT SUPPORT SYSTEM
What types of support do you currently have (if any)?
Select all that apply:
{"type":"checkbox","name":"Support_Current","width":50,"value":"","size":"Small","validation":"","validationMessage":"Please check at least one item.","options":"Caregiver (family, friend, etc.)\nCoach (mental health, benzo, etc.)\nCommunity (support group, etc.)\nGeneral Practitioner (Doctor, NP, PA)\nNaturopath / Functional Medicine\nNeurologist\nPsychiatrist\nTherapist / Counselor"}
Please provide any details regarding the above support individuals you would like share, or add any individuals not listed above.
{"type":"textarea","name":"Support_Current_Details","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":"Any additional information..."}
OTHER INFORMATION
LEARN ABOUT COACHINGHow did you learn about Uneven's coaching services?
{"type":"checkbox","name":"HearAboutUs","width":50,"value":"","size":"Small","validation":"","validationMessage":"Please check at least one item.","options":"Podcast (Benzo Free)\nPodcast (Uneven)\nReferral from a Community Leader\nReferral from a Friend\nSocial Media (Facebook, LinkedIn, etc.)\nThe Uneven Life Community\nThe Uneven Life Website\nOther (Please explain below)"}
Please add any details you would like to share.
{"type":"textarea","name":"Other_LearnAboutUs_Details","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":"How did you hear about us?"}
Thank you for taking the time to prepare for our session - I'm looking forward to our first meeting. Speak soon!
