Full NameDate of Birth MM slash DD slash YYYY Phone NumberEmail Address AddressEmergency Contact Name & RelationshipEmergency Contact Phone NumberWhat inspired you to seek mental health coaching at this time?What goals would you like to achieve through coaching? Improve mental clarity Reduce stress Emotional resilience Confidence/Self-worth Goal-setting Lifestyle balance Other OtherHave you ever worked with a coach, therapist, or counselor before? Yes No If yes, what was your experience like?Do you have a support system (friends, family, mentor)? Yes No Briefly describeHow would you describe your current emotional state? Generally positive Anxious or overwhelmed Low energy/motivation Difficulty focusing Other OtherAre you currently receiving therapy, counseling, or mental health services? Yes No If yes, please specifyDo you have any diagnosed mental health conditions? Yes No If yes, please specifyAre you currently taking any medications for mental or physical health? Yes No If yes, please listDo you have a mindfulness, journaling, or spiritual practice? Yes No If yes, please describe brieflyAre you open to tools like visualization, goal tracking, breathwork, journaling, or guided exercises? Yes No How committed are you to taking steps toward your goals between sessions? Fully committed Somewhat committed Not sure yet Is there anything else you'd like your coach to know?CAPTCHA
