Client Questionnaire

Client Questionnaire.

This form is confidential. Once you have completed this form, I will be in touch within 24 hours to book your first session if I think I can help.

Name

First Name

Last Name

Phone

(###)

###

####

Your preferred method of contact (phone or email)

Date of birth

Emergency Contact (not you)

Emergency Contact Phone Number

School or work details

What are you wanting to get out of life coaching?

Are you currently working with any mental health practitioner? (E.g. psychologist, therapist, counsellor etc?) Or, have you in the past?

Are you currently taking any medication for your mental health? If so, what?

On a scale of 1-10, how would you say your mental health is right now?

What days and times are you available for sessions?

Would you like an in person or online appointment?

Anything else you’d like me to know?

How did you hear about Asha Life Coaching?