NEW CLIENT INFORMATION FORM

Please provide the following information and answer questions below.

 

Client Information

Date:{"type":"text","name":"Date","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","maxlength":100,"placeholder":""}

Name:{"type":"text","name":"Name","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","maxlength":100,"placeholder":""}

 

Home Phone: {"type":"text","name":"HomePhone","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","maxlength":100,"placeholder":""}

 

Cell Phone:{"type":"text","name":"cellPhone","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","maxlength":100,"placeholder":""}

 

What is most important to you now that you feel wellness/resilience coaching can support?  And why is this so important to you?

 

{"type":"textarea","name":"__generic","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":"Reflection..."}

 

 

On a scale of 1-10, 1 (low readiness) 10 (high readiness), how ready, excited, or eager are you to engage in a program for personal and/or professional growth?

 

1 not ready/eager at all 2 3 4 5 somewhat ready, but unsure about what it will entail 6 7 8 9 10 Very ready and excited about this great opportunity! Perfect timing!{"type":"radio","name":"__generic","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"1 not ready/eager at all\n2\n3\n4\n5 somewhat ready, but unsure about what it will entail\n6\n7\n8\n9\n10 Very ready and excited about this great opportunity! Perfect timing!"}

 

 

 

Occupation: {"type":"text","name":"occupation","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","maxlength":100,"placeholder":""}

 

Date of birth: {"type":"text","name":"DOB","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","maxlength":100,"placeholder":""}

 

Please list the names and relationships of the five most important people in your life:

 {"type":"textarea","name":"importantPeople","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"maxlength":1000,"placeholder":""}

 

Do you have pets?  yes no{"type":"checkbox","name":"pets","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","options":"yes\nno"}

 

If yes, please list:{"type":"textarea","name":"pets2","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"maxlength":1000,"placeholder":""}

Education: {"type":"textarea","name":"education","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"maxlength":1000,"placeholder":""}

 

Do you have any sleep problems? yes no{"type":"checkbox","name":"sleep","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","options":"yes\nno"}

Explain: {"type":"textarea","name":"explanation","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"maxlength":1000,"placeholder":""}

Are you dealing with any past or current addictions?

  yes no{"type":"checkbox","name":"addictions","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","options":"yes\nno"}

 Explain:{"type":"textarea","name":"explanation2","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"maxlength":1000,"placeholder":""}

Have you had any issues with Depression, Anxiety, or ADD/ADHD?

  yes no{"type":"checkbox","name":"mentalHealth","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","options":"yes\nno"}

 

Describe: (include any medications/supplements you are taking)

{"type":"textarea","name":"__generic","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}

 

Are you currently seeing a therapist?

  yes no{"type":"checkbox","name":"therapist","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","options":"yes\nno"}

 

Are you usually: Early On-Time Running Late{"type":"checkbox","name":"promptness","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","options":"Early\nOn-Time\nRunning Late"}

 

How would you describe how you learn best? (ie. reading, listening, doing)

{"type":"textarea","name":"__generic","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}

 

 

How do you like to spend your free time?

 {"type":"textarea","name":"HobbiesSports","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"maxlength":1000,"placeholder":""}

 

Do you have a regular practice of meditation, mindfulness, or prayer? If so, please describe.

 {"type":"textarea","name":"vacation","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"maxlength":1000,"placeholder":""}