Confidential Client Intake Form Name * First Name Last Name Email * Phone * (###) ### #### Are you okay being contacted by text message Yes No Date of Birth MM DD YYYY Emergency Contact Name/Phone Number (###) ### #### Marital Status Single Married Partnered Widowed Divorced Polyamorous Preferred Pronouns Do you consider yourself spiritual/religious? How did you hear about Ember? TikTok Instagram Referral Google Medical History: Please check all that apply ADD/ADHD Alcohol/Drug Abuse Anxiety Depression Disordered Eating Emotional Abuse Physical Abuse Sexual Abuse Suicidal Thoughts Are you currently taking any medications? Have you had any surgeries or operations? Have you had any therapy or coaching services in the past 30 days? Are you currently seeing a therapist? Do you have any trouble sleeping? Are you dealing with any current addictions? How would you rate your overall health? Excellent Great Good Fair Poor Habits and Goals Are you usually Early On Time Running Late Do you exercise regularly Yes No If yes, please describe what you do and how often What are your hobbies? What do you do for fun? Goal Information - Please answer the following questions to the best of your ability What are your personal goals? What are your professional goals? What changes would you like to make in your life right now? What obstacles keep you from reaching your goals? How do you define success? Why have you decided to work with a coach? What parts of your life are working well? What parts of your life could be working better? What are your expectations from this coaching relationship? What would you like to focus on first when working with me? What do you consider your strengths? What do you consider your weaknesses? If you knew you couldn't fail, what would you love to do? Thank you! Please Fill Out This Form to the Best of Your Ability
