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Confidential Client Profile

For your coach only. Please answer all questions as completely as you are willing. Do not hesitate to ask any questions which arise.

Confidential Client Profile

Step 1 of 4

25%

Name*
First Last
Contact Information
Mobile Phone*
Home Phone
Other Phone
Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
In an Emergency, Contact:*
Emergency Contact Phone*

Personal Information
Gender*
- Male
- Female
Birth Date*
MM slash DD slash YYYY
Marital Status*
- Single
- Married/Domestic Partner
- Divorced
- Widowed
Spouse/Partner Name
Your Family & Close Circle
Please tell us with whom you live:*
Please tell us about your significant other:*
Please tell us about your parents:*
Were you adopted?*
- Yes
- No
You Said yes you were adopted. Do you know your birth parent(s)?
How many members are in your immediate family?*
Please tell us about your brothers and sisters:*
Please tell us about your children:*

Your History
Have you ever been hospitalized for medical or emotional reasons?*
- Yes
- No
You said you have been hospitalized. What should we know about this?
Have you ever been in an Accident or Other Traumatic Experience (e.g. Natural Disaster, War, Violent Crime, Etc.)?*
- Yes
- No
You said yes. Please explain.
Have you or your family members ever been arrested for and/or convicted of a felony?*
- Yes
- No
You said yes. Please explain in detail, including dates and the disposition of the case.
Have you or any of your family members ever been sexually molested or physically abused?*
- Yes
- No
How do you still feel affected by this?
Have you and/or any members of your immediate family declared bankruptcy?*
- Yes
- No
You said yes regarding bankruptcy, who and what year?
Has any family member or close friend died within the last year?*
- Yes
- No
Please provide the name, relationship and how close you were.

How many times have you moved in your life?*
How many times have you moved in the last year?*
Are you and/or any members of your immediate family currently in therapy and/or under the care of a doctor or other medical professional?*
- Yes
- No
You said yes, please explain.
Have you or any other member of your immediate family had difficulties with alcohol, drugs, or eating disorders?*
- Yes
- No
If yes, please explain, including, if family member(s), who were they? How did this impact your life?
Is there anything in your life that does not serve you that you might have difficulty giving up or letting go of?*
- Yes
- No
You said yes. What is it?
What in your life have you not been acknowledged for?*
What are your strengths?*
What are your weaknesses?*
Name
This field is for validation purposes and should be left unchanged.

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