Online Intake Form

Filling out this form is the first step in the process of hiring me as your therapist and/or coach. If you’re READY to get cracking on making your love life “Right”… Then…

Please fill out this brief form with as much detail as you can:

Date*
Name*
FirstLast
Birthdate (dd/mm/yyyy)*
Sex*
Email*
Phone*
Skype Name*
Sessions are by phone or by Skype, please provide the Skype name you would use (provided you have an account)
Address*
Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry
How did you hear about me?*
May I ask who?
If a friend, colleague or professional referred you, I'd love to know who they are so I can say thanks! and "gift" them a little something.
Occupation*
Children? *
Includes adopted children, step-children, foster children, etc...
Reason (or main complaint/issue) why you are considering therapy or coaching now?*
Give a brief account of the history and development of this issue (onset to present):*
Any previous attempts to address this issue?*
Results?*
Please rate your distress TODAY due to your issue? *
1 is feel good, not a problem – and 10 is worst ever
Please rate your distress GENERALLY due to your issue?*
1 is feel good, not a problem – and 10 is worst ever
What 3 things will be different/better in your life if this problem was gone:*
Give your top 3 goals for our sessions together:*
What do you think is holding you back from experiencing the life you want (list thoughts, feelings, resentments, beliefs and paradigms, emotions)? *
List other areas of your life that are affected by this problem.*
How are you doing in the areas of finances, friendships, family, freedom and fun? Any concerns?
In your opinion, in this moment, what can you change/ what actions can you take to have new rewarding experiences? *