COVID Self-Care Coaching Package - Guided Resilience

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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

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?

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Best time to call: {"type":"text","name":"contactTime","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","maxlength":100,"placeholder":""}

Is it ok to leave messages at these numbers? {"type":"text","name":"YesNo","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","maxlength":100,"placeholder":""}

If no, please list which number it is okay to leave a message: {"type":"text","name":"contactNumber","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","maxlength":100,"placeholder":""}

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

How long have you been living at your current address? {"type":"text","name":"timeInHome","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","maxlength":100,"placeholder":""}

 

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":""}

 

For appointment scheduling, what are the best:

 

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

 

days of the week: {"type":"text","name":"daysOfWeek","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","maxlength":100,"placeholder":""}

 

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

 

Emergency Contact Information:

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

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

Phone: {"type":"text","name":"emergencyPhone","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? {"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":""}

How would you rate your overall physical health? {"type":"checkbox","name":"physicalHealth","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","options":"Excellent\nGreat\nGood\nFair\nPoor"}

Do you have any sleep problems? {"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?

 {"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?

 {"type":"checkbox","name":"mentalHealth","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","options":"yes\nno"}

 

Are you currently seeing a therapist?

 {"type":"checkbox","name":"therapist","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","options":"yes\nno"}

 

Are you currently taking any medications?

 {"type":"checkbox","name":"medication","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","options":"yes\nno"}

 

 

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

 

How often do you exercise?

 {"type":"checkbox","name":"Exercise","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","options":"regularly\nsometimes\nnone"}

 

How often do you watch TV?

 {"type":"checkbox","name":"TV","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","options":"regularly\nsometimes\nnone"}

 

What are your favorite hobbies and sports?

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

What do you do for fun?

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

When you treat yourself, what are things you like to do?

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

 

What is your idea of a perfect vacation?

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

How did you hear about me?

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

 

 

 

 

 

 

 

 

 

Almost done! Please enter your payment information to complete your purchase.

You will be billed immediately $210.00.

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