Client Intake Form Client Intake Form Coaching client information Date(Required) MM slash DD slash YYYY Name(Required) First Last Phone(Required)Email(Required) Address(Required) City State / Province / Region Year of Birth(Required)What type of work do you do? If unemployed or retired, what type of work did you do?(Required)What are your three most resourceful personal strengths or characteristics?(Required) Add RemoveWhat outcomes would you like to accomplish?(Required)Have you engaged in coaching in the past? Describe the outcome of that experience:(Required)Have you utilized hypnosis in the past? Describe the outcome of that experience:(Required)When we complete our time together, how will you know it has been successful for you?(Required)Do you understand that coaching and hypnosis is a goal directed collaboration to help you accomplish your goals and is not healthcare, psychotherapy, or counseling?(Required) Yes No What are your current limitations in achieving your desired goals?(Required)Who are the supports in your personal or professional life that can help you accomplish your goals?(Required)What skills would help you move towards your desired outcomes?(Required)Do you have a mental health diagnosis from a doctor, psychiatrist, psychologist, or psychotherapist that I need to be aware of? If so, please indicate.(Required)Is there anything else you need to share with me that would be helpful to know for our time working together?(Required)Emergency Contact Name and Phone Number(Required)EmailThis field is for validation purposes and should be left unchanged.