Intake Background Information Autonomic Coaching

Name

First

Last

Date

Email

Phone

Have you ever received treatment from a therapist before?

Have you ever been hospitalised for a psychiatric illness?

Have you ever been in a Rehabilitation Facility for substance abuse?

If you answer yes to any of the above, when and where were you treated, and for how long? Please supply additional information and if possible available psychological reports.

Are you currently under any therapeutic or psychiatric treatment and what is the result or desired result of the treatment?

Have you ever had coaching before and what was the purpose of seeking help from a coach – what were the objectives of the coaching sessions?

What symptoms related to mental health are you currently displaying? Sadness, depression, anxiety, anger, etc.?

Could you please supply me with a short overview of your objectives for seeking help now? (What do you think you would like to get out of the time we spend together?)

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